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/ State of Oregon Department of Environmental Quality <br /> 2 �-0-0lo' i- (NQ(1 <br /> Annual Operation and Maintenance <br /> rilli <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> TARAS & AMBER SARAPIN 503-409-1939 <br /> Property Owner: Phone: <br /> 315 JANICE CT 105E02DA07600 <br /> Site Address: Parcel#: <br /> city: DETROIT County: Marion <br /> 555-16-006694-SEP 10/11/22 <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: AX2ORT System Serial#: 147064 <br /> Report Year: 2025 Date of Service Performed: 8/22/2025 <br /> Email Address: TARASSARAPIN@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> ri <br /> ❑ was maintenance performed as required by septic system rules and the manufacturer? <br /> I] ❑ 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 /> ❑ In Is the system failing? <br /> ❑ 0 Discharge of sewage to the ground surface? <br /> ❑ It Discharge of sewage to drain tiles or surface waters? <br /> ❑ 0 Sewage backup into plumbing fixtures? <br /> If you answered"Yes"on the last four questions,was a repair permit obtained? If not, explain: <br /> 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 *Certification Expiration: 3/28'2026 <br /> ('This Iine-orllyran •:SJIetou[andfhoto ,•„[g <br /> ii �_ 12/31/2025 <br /> Original Signature: yL Date: <br /> Note: Maintenance providers must .intain accurate reco •s of their maintenance contracts, customers, <br /> performance data, and timeli -s for -newing the contracts. These records must be available for inspection upon <br /> request by the agency per OA- - r-• 1-0130(24). <br /> DEU Arnrialtt:ralon alio r'- itenance Rern roc... Rev 6:21)22 <br />