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State of Oregon Department of Environmental Quality aa © � &Q <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> C� 1-a5 a5 <br /> General Information (Complete ALL information) <br /> Property owner: MATTHEW FARRIS Phone: 503-258-7498 <br /> s eAddress: 10537 MATTHIEU LN. NE Parcel 041W08B000300 <br /> City: AURORA County: MARION <br /> 04-07728 7/21/2025 <br /> Permit#: Startup date if 1st year in use: <br /> System Model#: 20N System Serial#: LOGO <br /> Report Year: 2025 Date of Service Performed: 7/21/2025 <br /> Email Address: MATT.FARRIS76@YAHOO.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 /> x❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ Q Is the system failing? <br /> ❑ ❑� Discharge of sewage to the ground surface? <br /> ❑ Q 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 /> •"' START UP DONE AFTER 7/1/2025 *'•" <br /> 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 out <br /> Original Signatu e Date: 12/31/2025 <br /> Note: Maintenance prov ers ust main ' urate record of their maintenance contracts, customers, <br /> performance data, and tim ' s for renewing the contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEO Annual Operavon and Maintenance Report Forvn Rev 6/2022 <br />