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I -7- 00077 - /N (� <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> ova <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: BRAD BENSON Phone: 503-349-8980 <br /> Site Address: 9758 LARIAT LN. NE Parcel#: 041 W19C000402 <br /> City: AURORA county: Marion <br /> Permit#: 555-13-005715 Start up date if 1st year in use: 2/29/16 <br /> System Model#: '4X20RT System Serial#: 132430 <br /> Report Year: 2025 Date of Service Performed: 6/17/2025 <br /> Email Address: brad.benson@comcast.net <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> --L'J - ❑ --Wag maintenance performed as required by septic system rules and the manufacturer? <br /> O ❑ 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 /> ❑ ❑� Is the system failing? <br /> ❑ Q Discharge of sewage to the ground surface? <br /> ❑ ❑� Discharge of sewage to drain tiles or surface waters? <br /> D 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 ihatthis-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 it: M 587 *Certification Expiration: 3/28/2026 <br /> (*This line only can be IIeTput and phot ietl.) <br /> Original-Sigrret . 12/31/2025 <br /> Date: <br /> Note: Maintenance providers aintain a ur e records of their maintenance contracts,customers, <br /> performance data,and timelines for renewing the ntracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEO Annual Operation and Maintenance Report Fomr Pcv 62022 <br />