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State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance VV <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: Jordan Sparks Phone: 503-763-0949 <br /> Site Address: 2378 STEIWER RD Parcel#: 093W14D001500 <br /> City: JEFFERSON county: Marion <br /> Permit#: 08-01262 Start up date if 1st year in use: NA <br /> System Model#: AX2O-1 A System Serial#: 114661 <br /> Report Year: 2025 Date of Service Performed: 2/28/2025 <br /> Email Address: Jordan@opendental.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> El El Was maintenance performed as required by septic system rules and the manufacturer? <br /> 0 LI 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 /> ❑ in Is the system failing? <br /> ❑ ❑� Discharge of sewage to the ground surface? <br /> ❑ 111Discharge of sewage to drain tiles or surface waters? <br /> ❑ NI 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 Jr 587 *Certification Expiration: 3/28/2026 <br /> ('This line only can fill d out and p tocopied.) <br /> Original Signature Date: <br /> 12/31/2025 <br /> Note: Maintenance provider st aintain a urate records of their maintenance contracts, customers, <br /> performance data,and timeli for newing t e contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-0 0130( 4). <br /> DEC Annual Operation and Maintenance Report F or Reir a,2022 <br />