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2 .- 00I811 - /Nk / <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: SCOTT & TANYA BLOOMFIELD Phone: 503-931-1673 <br /> Site Address: 9548 BATES RD. Parcel#: 081 W31 B 01700 <br /> City: AUMSVILLE county: Marion <br /> 555-19-006987-PRMT 3/6/20 <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: AX2ORT System Serial#: 140392 <br /> Report Year: 2025 Date of Service Performed: 8/7/2025 <br /> Email Address: mrsbloomy@gmail.corn <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> 0 ❑ 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 /> x❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ Q Is the system failing? <br /> ❑ MI Discharge of sewage to the ground surface? <br /> ❑ ❑� Discharge of sewage to drain tiles or surface waters? <br /> D ❑ 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 ceHify 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 led o—d and ph,. scaled. <br /> Original Signature: r --- - > Date: 1 Z/31/Z025 <br /> Note: Maintenance pro ••ers mus ma -in ac• rate records of their maintenance contracts, customers, <br /> performance data, and tim ' es ,.r renewin• I e contracts. 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 Farm Rev 6/2022 <br />