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State of Oregon Department of Environmental Quality bb I Dl6-vtcl 1 <br /> 144 Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: SONJA CALLIS Phone: 541-908-2064 <br /> Site Address: 17346 WALL LN Parcel it: 102W180001000 <br /> City- JEFFERSON County: Marion <br /> Permit 555-21-004479-PRMT Start update if lstyear in use: UNKNOWN <br /> System Model#: PRESSURE DISTRIBUTION System serial#: N/A <br /> Report Year: 2025 Date of Service Performed: 10/29/2025 <br /> Email Address: SONJA.CALLIS@OUTLOOK.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> 0 -£I Was maintenance performed as required by septic system rules and the manufacturer? <br /> I] ❑ 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 /> ❑ II Is the system failing? <br /> ❑ I] Discharge of sewage to the ground surface? <br /> ❑ D Discharge of sewage to drain tiles or surface waters? <br /> ❑ • 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 ItM 587 *Certification Expiration: 3/28/26 <br /> ('This line only can berg ouT$nd p tocopi .) <br /> Original Signature: `_ Date: 12/31/2025 <br /> Note: Maintenance providers st aintain u e records of their maintenance contracts,customers, <br /> performance data, and timelines o renewing the contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DFO Annual Operalim arm Ma penance R Fain It_ 612022 <br />