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2.5-000 '%- 1A1&J <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: BRIAN BOOCK Phone: 503-580-3940 <br /> s Address: 7011 LITTLE RD. Parcel#: 082W3401200 <br /> AUMSVILLE ty: Marion <br /> City: County: <br /> Permit#: Start Start up date if 1st year in use: 2/7/22 <br /> AX2ORT 145015 <br /> System Model#: System Serial#: <br /> Report Year: 2025 Date of Service Performed: 9/23/2025 <br /> Email Address: BVBOOCK@AOL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> x❑ 0 Was maintenance performed as required by septic system rules and the manufacturer? <br /> 9 ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> ❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ © Is the system failing? <br /> ❑ 0 Discharge of sewage to the ground surface? <br /> ❑ Q 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 /> 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 54;ai Sand photocop e . <br /> Original Signature: L y 1 Date: 12/31/2025 <br /> Note: Maintenance providers us fain accurate reco s of their maintenance contracts, customers, <br /> performance data, and timelines newing . These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEC Annual operation ann Maintenance Report Forn Rev 6i2022 <br />