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L7- O00736- 1 iJt <br /> _prig State of Oregon Department of Environmental Duality <br /> Annual Operation and Maintenance <br /> will <br /> DEQ Report Form <br /> General Information (Complete ALL Information) <br /> Property Owner: DENNIS BETHEL Phone: 503-507-3816 <br /> 6976 LITTLE RD. 092W03B000100 <br /> Site Address: Parcel#: <br /> city: TURNER county: Marion <br /> Permit#: 10-07350 Start up date if 1st year in use: 1/13/1 Z <br /> AX2ON RTUV 413874 <br /> System Model#: System Serial#: <br /> Report Year: 2025 Date of Service Performed: 7/30/2025 <br /> Email Address: Office@BETHELEXC.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> x❑ ❑ 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 /> ❑ ❑� Is the system failing? <br /> ❑ IN Discharge of sewage to the ground surface? <br /> ❑ in Discharge of sewage to drain tiles or surface waters? <br /> ❑ El 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#: *Certification 587 *Certification Expiration: 3/28/2026 <br /> ('This line only can be fille nd photoco•`: <br /> Original Signature: - -- /1. •_ ------� Date: <br /> 12/31/2025 <br /> Note: Maintenance providers mu -•• accurate reco •s of their maintenance contracts, customers, <br /> performance data,and timelines for renewing t - • ---. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEG Annual Operation and Maintenance Report Form Rev.612022 <br />