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/`d." State of Oregon Department of Environmental Quality \ — O"b°‘5-1 SA Annual Operation and Maintenance DEQ Report Form General Information (Complete ALL information) Property Owner: Uli Sparks Phone: 503-580-8449 16042 Stormy Dr Parcel#: 071 E06D002500 Site Address: City: Silverton county., Marion Permit#: 08-08564 Start up date if 1st year in use: 3/24/2009 20-1 B System Serial#: 115419 System Model#: Report Year: 2025 Date of Service Performed: 3/14/2025 Email Address: uIisparks@9mail.com Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) Yes No ❑ ❑ Was maintenance performed as required by septic system rules and the manufacturer? x❑ ❑ Is the system operating in accordance with the agent-approved design specifications? l ❑ Is the system currently under a service contract with a certified maintenance provider? ❑ ❑D Is the system failing? ❑ In Discharge of sewage to the ground surface? ❑ In Discharge of sewage to drain tiles or surface waters? ❑ IN Sewage backup into plumbing fixtures? If you answered"Yes"on the last four questions,was a repair permit obtained? If not, explain: I certify that this report is complete and accurate to the best of my knowledge. I understand that falsification of this report is grounds for revocation of my certification and/or civil penalties. 'Maintenance Provider Name (please print): CORD MORGAN - A & B Septic Service *Certification#: M 587 'Certification Expiration: 3/28/26 ('This line only can be ed out and - to iffis And 12/31/2025 Original Signature: 1. Date: Note: Maintenance providers ust aintain=ccurate records of their maintenance contracts, customers, performance data, and timel >< for enewin• the contracts. These records must be available for inspection upon request by the agency per OAR 340-1 1-01 r(24).