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_ern, State of Oregon Department of Environmental Quality <br /> 31.- a�a5 A)DY <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: ANTHONY CORSON Phone: 503-383-8233 <br /> Site Address: 118 N. SANTIAM HWY Parcel#: 093E27DA01800 <br /> City: GATES County: MARION <br /> 555-21-003030-PRMT -7/18/25 <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: LPD System Serial#: NA <br /> Report Year: 2025 Date of Service Performed: <br /> Email Address: CORSONSUSAN@YAHOO.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> El D 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 /> El El Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ® Is the system failing? <br /> ❑ Q Discharge of sewage to the ground surface? <br /> El ® Discharge of sewage to drain tiles or surface waters? <br /> El 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 /> F 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 II out and :> .pin.,) <br /> Original Signature: _a A I = Date: 12/31/2025 <br /> Note: Maintenance prov ers m t maintain at records of their maintenance contracts,customers, <br /> performance data,and ti lines or renewing the contracts. These records must be available for inspection upon <br /> request by the agency per 0 340-071-0130(24). <br /> DLO Annual operation and )lai uteri a'r,e keport Irons Rev 6:2C22 <br />