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11- 000gi1- 144 <br /> / State of Oregon Department of Environmental Quality <br /> �31 Annual Operation and Maintenance <br /> rill <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: BRIAN BLISS Phone: 503-510-7243 <br /> 11080 Dogwood Lane SE parcel#: 093E18BA00301 <br /> Site Address: <br /> City. Lyons county: Marion <br /> r <br /> 07-05420 Start u date if 1st year in use: 12/3/2007 <br /> Permit#: P <br /> System Model it: AX20-1 B System Serial#: 113509 <br /> Report Year: 2025 Date of Service Performed: 10/3/2025 <br /> Email Address: blissbe@hotmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> ❑ ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> x❑ ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> Q ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ MI Is the system failing? <br /> O I] Discharge of sewage to the ground surface? <br /> ❑ Q Discharge of sewage to drain tiles or surface waters? <br /> ❑ I• 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 and p pied) <br /> 12/31/2025 <br /> Original Signature: - - Date: <br /> Note: Maintenance providers u main urate records of their maintenance contracts, customers, <br /> performance data,and timelines for renews e contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEO Annual 0 per alion and Maintenance Renal Fonn Rev.6/2022 <br />