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-Erg, State of Oregon Department of Environmental Quality eg iA. <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: HEATHER & ROBERT CACAK Phone: 503-910-0028 <br /> Site Address: 35195 RUTH ST. SE Parcel#: 084E32BC03600 <br /> City: LYONS County: MARION <br /> 555-21-009528-PRMT-01 NA <br /> Permit#: Startup date if 1st year in use: <br /> System Model#: PRESSURE DIST System Serial#: N/A <br /> Report Year: 2025 Date of Service Performed: 7/25/2025 <br /> Email Address: HEATHERCACAK@GMAIL.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 /> x❑ El 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 /> ❑ 0 Is the system failing? <br /> El ❑� Discharge of sewage to the ground surface? <br /> ❑ IU Discharge of sewage to drain tiles or surface waters? <br /> El 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#: M 587 *Certification Expiration: 3/28/2026 <br /> ('This line only can be ut • <br /> Original signature Date: 12/31/2025 <br /> Note: Maintenance providers mu 3 .ntain a rater ords of their maintenance contracts, customers, <br /> performance data, and timelines for renewing the contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEC Annual Operatron and Maintenance Report Form Rev.6:2022 <br />