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$-7— pvo9t19— INQ <br /> 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: DAVE SLOAN Phone: 503-302-1025 <br /> Site Address: 20658 ABIQUA ROAD 071E13B 00800 <br /> Parcel#: <br /> City: SCOTTS MILLS Marion <br /> County: <br /> Permit#: 555-05-04850 UNKNOWN <br /> Start up date if 1st year in use: <br /> System Model#: AX2ON 105144 <br /> System Serial#: <br /> Report Year: 2025 Date of Service Performed: 12/1/2025 <br /> Email Address: d-sloan@Iive.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> ❑ 0 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 /> ❑ 0 Is the system failing? <br /> ❑ ® Discharge of sewage to the ground surface? <br /> ❑ 8 Discharge of sewage to drain tiles or surface waters? <br /> ❑ © 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): Coy Morgan - A & B Septic Service <br /> 'Certification#: M 587 *Certification Expiration: 3/28/2026 <br /> ('This line only can be ut and photocopied.) <br /> Original Signature: Date: 12/31/2025 <br /> Note: Maintenance providers mu t mai tain accurat records of their maintenance contracts,customers, <br /> performance data, and timelin f ren ing the con cts. These records must be available for inspection upon <br /> request by the agency per OAR -071-0 24). <br /> DEO Annual Operation and Maintenance.Report Form Rev.6/2022 <br />