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State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: TOM SOVA Phone: 503-368-7001 <br /> Site Address: 703 1ST ST 061E15CD00102 <br /> Parcel#: <br /> City: SCOTTS MILLS Marion <br /> County: <br /> Permit#: 555-20-007841 12/22/23 <br /> Startup date if 1st year in use: <br /> AX2ORT 145572 System Model#: <br /> System Serial#: <br /> Report Year: 2025 8/5/2025 <br /> P Date of Service Performed: <br /> Email Address: TLSOVA@AOL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> Q 0 Was maintenance performed as required by septic system rules and the manufacturer? <br /> El ❑ 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 /> ❑ © Is the system failing? <br /> ❑ Discharge of sewage to the ground surface? <br /> El Q Discharge of sewage to drain tiles or surface waters? <br /> ❑ It 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 es •ut and p.oto..•ied.) <br /> Original Signatur-: <br /> talk Date: 12/31/2025 <br /> Note: Maintenance providers must a' tam accura records of their maintenance contracts,customers, <br /> performance data, and timelines F. r-newrng the con acts. These records must be available for inspection upon <br /> request by the agency per OAR 340-171-0130(24). <br /> DEQ Annual Operanon and to a ntenance Report - in Rev 612022 <br />