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-e-tmg, State of Oregon Department of Environmental Quality 11-thtJ1l o- iA0 <br /> Annual Operation and Maintenance <br /> WVII <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: Karen Brooks Phone: 503-871-8800 <br /> 4622 Brooks Ln SE 092W20B 01004 <br /> Site Address: Parcel#: <br /> Turner County: <br /> Marion <br /> City: <br /> Permit#: 10-04498 Start update if 1st NA <br /> year in use: <br /> System Model#: AX2ORT System Serial#: 122002 <br /> Report Year: 2025 Date of Service Performed: 10/13/2025 <br /> Email Address: rickar.11c@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> a ' ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> Q 0 Is the system operating in accordance with the agent-approved design specifications? <br /> E ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ .1 Is the system failing? <br /> ❑ RE Discharge of sewage to the ground surface? <br /> ❑ IN Discharge of sewage to drain tiles or surface waters? <br /> ❑ II Sewage backup into plumbing fixtures? <br /> If you answered'"Yes"on the last four questions,was a repair permit obtained? If not, explain: <br /> r certifitfiatthhrsreport 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 587 'Certification Expiration: 3/28/2026 <br /> ('This line only can •_ Ile, out and photocopied.) <br /> — <br /> Original Signature: 94--1 \\ ��� Date: 12/31/2025 <br /> Note: Maintenance providerslrMst main accurat- records of their maintenance contracts, customers, <br /> performance data, and timelines for renewing r = •• acts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DE()Amnia Operation and Maintenance Report Form Pee.6/2022 <br />