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CCI <br /> -/-`g. State of Oregon Department of Environmental Quality R"'- I�a� 11 (\ <br /> Annual Operation and Maintenance (/ VVV <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: JULIAN BARTON Phone: 503-329-9661 <br /> 6869 CHAMPOEG RD. NE Parcel#: <br /> 042W030000300 <br /> Site Address: <br /> City: ST. PAUL county: Marion <br /> Permit#: UNKNOWN Start up date iftstyearinuse: 6/19/24 <br /> System Model#: AX2ORT System Serial#: 150992 <br /> Report Year: 2025 Date of Service Performed: 7/21/2025 <br /> Email Address: BARTONJULIAN42@GMAIL.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 ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ 0 Is the system failing? <br /> ❑ NI Discharge of sewage to the ground surface? <br /> ❑ ® Discharge of sewage to drain tiles or surface waters? <br /> El ID 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 filled put and h copied.) <br /> Original Signature: Date: 12/31/2025 <br /> Note: Maintenance providers t mai in ccurate records of their maintenance contracts, customers, <br /> performance data,and timelines for renew. the contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> IJLQ Annual Operation and Maintenance Reoort Form Rev.62022 <br />