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22 poz9tt3 - ? JQH <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: APRIL SCHMIDT Phone: 503-999-1929 <br /> Site Address 20291 OLMSTEAD RD NE Parcel#: O41W19B 01400 <br /> City: AURORA County Marion <br /> Permit#: 555-21-002692-PRMT Start update if 1st year in use: 12/8/21 <br /> System Model#: SINGULAIR System Serial#: ZX29O193 <br /> Report Year: 2025 Date of Service Performed: 5/29/2025 <br /> Email Address: schmidt973O6@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> +❑ ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> 111 ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> ❑ ❑ 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 /> ❑ In 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 /> M 5!o <br /> 'Certification#: (\r 5 'Certification Expiration: 3/28/2026 <br /> ('This line only can be Need out nd photoc9Died.) <br /> G 12/31/2025 <br /> Original Signature: Date: <br /> Note: Maintenance providers ust aintain -ccurate -cords of their maintenance contracts,customers, <br /> performance data, and timeline enewi • the cons-cts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130 . <br /> DEQ Ann uai Operalien and M iniename Resort Form Rev 6:21)22 <br />