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d' LD dD1l-1 TriO�1J� <br /> State of Oregon Department of Environmental Quality v J <br /> Annual Operation and Maintenance <br /> raVII <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: MARK ALLEN Phone: 503-708-3410 <br /> Site Address: 261 CEDAR AVE Parcel#: 10S06E16D00400 <br /> City: IDANHA County: MARION <br /> Permit#: 555-22-005977 Start up date if 1st year in use: 06/17/2024 <br /> System Model#: AX2ORT System Serial#: LOGO <br /> Report Year: 2025 Date of Service Performed: 12/10/2025 <br /> Email Address: MARK@VISUALTRANSLATIONS.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> Q ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> Q ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> Q El Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ❑� Is the system failing? <br /> ❑ ❑� Discharge of sewage to the ground surface? <br /> ❑ Q Discharge of sewage to drain tiles or surface waters? <br /> El 0 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 it: M 587 "Certification Expiration: 3/28/2026 <br /> ("This line only can be fir• out , oto ••ied.) <br /> 1.1 <br /> Original Signature: �rI Date: 12/31/2025 <br /> v II <br /> Note: Maintenance providers" nus ain;:in accurate records of their maintenance contracts, customers, <br /> performance data, and timelines for r-•e ing the contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> ui :, i.,oeraton VICe i _:F . Rev � '01L <br />