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State of Oregon Department of Environmental Quality 19G2—C/I J I k " <br /> 044 Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: JEFF ASHWELL Phone: 503-881-1328 <br /> 9486 LEWIS DR. SE 092W01C001600 <br /> Site Address: Parcel#: <br /> C. AUMSVILLE County: MARION <br /> City: <br /> Permit#: 555-24-006146-PRMT Start up date if 1st year in use: 3/12/25 <br /> System Model#: AX2ORT System Serial#: LOGO <br /> Report Year: 2025 Date of Service Performed: 10/22/2025 <br /> Email Address: JASHWELL01@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> O 0 Was maintenance performed as required by septic system rules and the manufacturer? <br /> I] ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> Q ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ I] Is the system failing? <br /> ❑ In Discharge of sewage to the ground surface? <br /> ❑ • Discharge of sewage to drain tiles or surface waters? <br /> ❑ Q Sewage backup into plumbing fixtures? <br /> If you answered"Yes"on the last four questions,was a repair permit obtained? If not, explain: <br /> I certify that this report is complete and accurate to the best of my knowledge. I understand that falsification of this <br /> report is grounds for revocation of my certification and/or civil penalties. <br /> *Maintenance Provider Name(please print): Cory Morgan - A & B Septic Service <br /> `Certification#: M 587 *Certification Expiration: 3/28/2026 <br /> ('This line only can be fil out and hotocopied.) <br /> Original Signature: l lc - Date: 12/31/2025 <br /> Note: Maintenance provider's ust m ' lain a rate records of their maintenance contracts, customers, <br /> performance data,and timelines for rene ' e contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEQ annual Opermien and Maintenance R2part Form Rev 6:2022 <br />