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1- -0e09113 -1NQ <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: Sandi Ryan-Nelson Phone: 503-932-3678 <br /> Site Address: 4026 Edison Rd NE Parcel#: 071W02C 03000 <br /> City. Silverton County: Marion <br /> 06-02934 NA <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: AX2O-1 A System Serial#: 108762 <br /> Report Year: 2025 Date of Service Performed: 11/20/2025 <br /> Email Address: nelson.sandra.t@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 /> 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 /> ❑ ❑fi Is the system failing? <br /> ❑ • Discharge of sewage to the ground surface? <br /> ❑ I] Discharge of sewage to drain tiles or surface waters? <br /> ❑ I] Sewage backup into plumbing fixtures? <br /> If you answered"Yes"on the last four questions,was a repair permit obtained? If not,explain: <br /> 1 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 587 3/28/2026 <br /> 'Certification#: 'Certification Expiration: <br /> (*This line only can be ed o tend p . . ..':d.) <br /> Original Signature: / „of Date: 12/31/2025 <br /> Note: Maintenance provi•-rs mu 4 mai'lain accuraf. records of their maintenance contracts,customers, <br /> performance data, and tim- ' es or ren> ing the co tracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0 • 24 <br /> DLO Doopol peatior and Lloorterm.e R_pou Form Rev 32G22 <br />