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State of Oregon Department of Environmental Quality a�-VD" 5 Vu\e <br /> Annual Operation and Maintenance <br /> DEQ` Report Form <br /> General Information (Complete ALL information) <br /> Property owner: MARK COURTNEY Phone: 503-910-2330 <br /> Site Address: 120 E. SORBIN AVE. Parcel#: 093E26CC03200 <br /> C y: GATES County: MARION <br /> Permit#: 555-21-008417-PRMT Start up date if 1st year in use: NA <br /> System Model#: PRESSURE DISTRIBUTION System Serial#: <br /> NA <br /> Report Year: <br /> 2025 Date of Service Performed: 12/31/2025 <br /> Email Address: BANKIT2@HOTMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> *❑ ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> x❑ ❑ 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 /> ❑ II Is the system failing? <br /> ❑ Q Discharge of sewage to the ground surface? <br /> ❑ Q 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 filled out and photocopied.) <br /> Original Signature: ` ,,r1 • Date: 12/31/2025 <br /> 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 /> DECP pc ia'.ono NI „_n..nce PopolF oem ov 52a22 <br />