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aL -Do a as-rJsL? <br /> .ram State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> USX, ` aiDiVa5 <br /> General Information (Complete ALL information) <br /> ROSS & KAREN JAEGER 503-624-2883 <br /> Property Owner: Phone: <br /> 13216 DOWNS RD. NE 061W2200200 <br /> Site Address: Parcel#: <br /> MT. ANGEL MARION <br /> City. County: <br /> 555-13-00490 10/23/25 <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: AX2ORT System Serial#: LOGO <br /> Report Year: 2025 Date of Service Performed: <br /> Email Address: ROSSJ@WOODBURNNURSERY.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> O Li 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 /> E ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ I] Is the system failing? <br /> ❑ It Discharge of sewage to the ground surface? <br /> ❑ ® Discharge of sewage to drain tiles or surface waters? <br /> ❑ IN 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 /> 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 , t and photocopied. __. / <br /> r( l.J <br /> --- 12/31/2025 <br /> Original-Signature: Date: <br /> Note: Maintenance provi maintain accurate r=.ords of their maintenance contracts,customers, <br /> performance data,and time !!:r renewing the contr- s. These records must be available for inspection upon <br /> request by the agency per OAR 341-r- • r <br /> GCO Operation Ma uarm:a Papaw -um <br />