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f-1 —CMS 10-1_iQ <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Prope yowner HEATHER & CODY SNYDER phone: 503-851-4861 <br /> Site Address 9223 WEST STAYTON RD Parcel 092W01B000500 <br /> City: AUMSVILLE County: Marion <br /> Permit#: 06-03955 Start up date if 1st year in use: 07/27/2009 <br /> System Model if: AX2ON System Serial#: 105316 <br /> Report Year: 2025 Date of Service Performed: 7/18/2025 <br /> Email Address HEATHERSNYDER2004@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> x❑ ❑ 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 /> ❑ ID Discharge of sewage to the ground surface? <br /> ❑ ID 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: <br /> . 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 /> EC:AFTLIS'Oponlion 2nr.Nfaintrnance Popo.. crm uev.. rzozs <br />