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State of Oregon Department of Environmental Quality I 7- Q <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> ROBERT SIGLOH Phone: 503-806-6010 <br /> Property Owner: <br /> Site Address: 17433 MARSH RD Parcel#: 042W36C000800 <br /> City WOODBURN County: Marion <br /> Permit#: 11-05756 Start up date if 1st year in use: NA <br /> System Model# AX20 RT System Serial#: 133179 <br /> Report Year: 2025 Date of Service Performed: 12/31/2025 <br /> Email Address: bobmac1948@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> Q ❑ 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 /> ❑ El Is the system failing? <br /> ❑ l] Discharge of sewage to the ground surface? <br /> ❑ ❑� Discharge 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#: 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 /> DEC A I Opesationa f to...nx P I 'C' OL^' R=v rJ[Wt <br />