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25- 009kqs- ( /J QLi <br /> . _ State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> wa <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> THURSTON ROBINSON 808-283-4066 <br /> Property Owner: Phone: <br /> Site Address: 112 SANTIAM AVE. W Parcel#. 105E02DA03500 <br /> City: DETROIT Marion <br /> County: <br /> Permit#: 555-22-002432 Start up date if 1st year in use: 7/8/2024 <br /> System Model#: AX2ORTN System Sepal#: LOGO <br /> Report Year: 2025 Date of Service Performed: 8/6/2025 <br /> Email Address: HLSKEAKA@AOL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> O ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> E ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> O El Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ • Is the system failing? <br /> tEl Q Discharge of sewage to the ground surface? <br /> ❑ • Discharge of sewage to drain tiles or surface waters? <br /> ❑ It 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 it: "7 *Certification Expiration: 3/28/2026 <br /> ('This line only can •- filled but and phut• Deject r <br /> Original Slgnatur : 1Yi ) A ' " Date: 1 Z/31/2025 <br /> Note: Maintenance providers fain - urate records •f their maintenance contracts, customers, <br /> performance data, and timeline-wing ' - contracts. hese records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> BEG Annual operation and Maintenance Report F can Rev o:202:r <br />