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23—ac)10(1 -1004 <br /> -/'Q_ 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: KYLE RAMSAY Phone: 503-201-5844 <br /> 8092 BISHOP RD. SE 81W3100500 <br /> Site Address: Parcel#: <br /> City: AUMSVILLE County: Marion <br /> Permit#: 555-21-006842 Start up date if 1st year in use: 06/17/2022 <br /> System Model#: '4XZORT System Serial#: 145569 <br /> Report Year: 2025 Date of Service Performed: 7/28/2025 <br /> Email Address: ramsay68@yahoo.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> -u -❑ -Was maintenance performed as required by septic system rules and the manufacturer? <br /> I] LI Is the system operating in accordance with the agent-approved design specifications? <br /> I] ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ IN Is the system failing? <br /> ❑ It Discharge of sewage to the ground surface? <br /> ❑ It 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 /> I certi 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): Coy Morgan - A & B Septic Service <br /> 'Certification#: M 587 *Certification Expiration: 3/28/2026 <br /> (*This line only can be led oft and pho .) • <br /> Original signature: Date: 12/31/2025 <br /> Note: Maintenance provide must m intain - ,urate records of the maintenance contracts, customers, <br /> performance data,and timelin for r newing the ..- -cts. These -cords must be available for inspection upon <br /> request by the agency per OAR - 71-0130(24). <br /> lit raAnnual Operation N.: .eaance Repot Fern Rea 6:'_022 <br />