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0-000931 1NQ <br /> / State of Oregon Department of Environmental Quality <br /> Sail Annual Operation and Maintenance <br /> ra <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: BRANDON RITZMA Phone: 208-620-0126 <br /> s Address: 5874 WILLIAM WAY SE Parcel#: 092W33 00404 <br /> City: TURNER County: Marion <br /> Permit#: 555-15-006162 Start up date if 1st year in use: NA <br /> System Model#: AX2ORT UV System Serial#: 132333 <br /> Report Year: 2025 Date of Service Performed: 10/22/2025 <br /> Email Address: BRANDONRITZMA@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 /> El ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> E El Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ Ill Is the system failing? <br /> El I] Discharge of sewage to the ground surface? <br /> ❑ III Discharge of sewage to drain tiles or surface waters? <br /> ❑ In 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#: 1vI 587- - "---- •Certification Expiration: 3/28/2026 <br /> (*This line only can be Iletl o t and pho - -- — <br /> Original Signature: h ♦` 'SS Date: 12/31/2025 <br /> Il <br /> Note: Maintenance providers aintain of their maintenance contracts, customers, <br /> performance data, and timelines : enewing the co ese records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEG Annual Operation and Maintenance Report Farr. Rev.6i2022 <br />