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State of Oregon Department of Environmental Quality n — C - b( ur,b <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Propertyowner: JAQUIE SPENNER 503-559-2987 <br /> Phone: <br /> 10742 LEVERMAN RD. SE. 081 W32B00300 <br /> Site Address: Parcel#: <br /> City: AUMSVILLE Marion <br /> County: <br /> 555-15-004789-SEP <br /> Permit#: Start up date if 1st year in use: NA <br /> DELTA NA System Model#: <br /> System Serial#: <br /> Report Year: 2025 10/28/2025 <br /> P Date of Service Performed: <br /> Email Address: SiSpenner@aol.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 /> 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 /> ❑ ❑� Is the system failing? <br /> O ID Discharge of sewage to the ground surface? <br /> ❑ • Discharge of sewage to drain tiles or surface waters? <br /> D B 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. (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 5$7 'Certification Expiration: 3/28/2026 <br /> ('This line only can be fill=• . t am. . oco.ied. <br /> r/ 12/31/2025 <br /> Original Signature: Date: <br /> Note: Maintenance providers st maint.in accurate records of their maintenance contracts,customers, <br /> performance data, and timeli -- for rene 'ng the contracts, These records must be available for inspection upon <br /> request by the agency per OA• 340-071 r 130(24), <br /> I)F0 An ndal Oneraune aN"vai'tenanQ a . t Foam <br /> Rev 122222 <br />