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cal— Db13ak_ <br /> 1 State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> vie <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Propertyowner: GEORGE COBOL Phone: 503-428-7081 <br /> 27760 N. SANTIAM HWY 092E25D00800 <br /> Site Address: Parcel#: <br /> city: MILLS CITY county: MARION <br /> Permit#: 555-23-006797-PRMT NA <br /> Start up date if 1st year in use: <br /> System Model#: PRESSURE DIST System Serial#: NA <br /> Report Year: 2025 Date of Service Performed: 12/31/2025 <br /> Email Address: NSANTIAMFENCE@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> I] 0 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 /> x❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ UJ Is the system failing? <br /> El ❑1 Discharge of sewage to the ground surface? <br /> ❑ MI Discharge of sewage to drain tiles or surface waters? <br /> ❑ III 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): Coy Morgan - A & B Septic Service <br /> *Certification#: M 587 *Certification Expiration: 3/28/2026 <br /> ('This line only can be filled out and photocopies ed.) <br /> Original signature: ` Date: 12/31/2025 <br /> ir.Note: Maintenance providers must maintain accurate records of their maintenance contracts,customers, <br /> performance data, and timelines for renewing the contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEu !opentlo d Vaniorrioro r<eport row r Nov 512022 <br />