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„. 'k, 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 RODNEY BICKLE Phone: 503-586-3767 <br /> s Address: 12308 CHECKERBOARD RD. Parcel it: 052W35BA00900 <br /> City: GERVAIS canny: Marion <br /> Permit#: 13-02332 Start up date d 1st year in use:AX <br /> N/A <br /> System Model#: 20-1 B System Serial#: 128926 <br /> Report Year: 2025 Date of Service performed: 9/17/2025 <br /> Email Address: RBICKLE@KBBLLLC.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> Q ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> Q 0 Is the system operating in accordance with the agent-approved design specifications? <br /> Q ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ® Is the system failing? <br /> ❑ ® Discharge of sewage to the ground surface? <br /> ❑ • Discharge of sewage to drain tiles or surface waters? <br /> ❑ it 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(pyease print): Cory Morgan - A & B Septic Service <br /> *Certification#: M 587 'Certification Expiration: 3/28/2026 <br /> ('This line only can be fit d and photocopied.) <br /> Original Signature: v or- <br /> II Date: 12/31/2025 <br /> Note:Maintenance provi mu m-'ntain a •urate records of their maintenance contracts,customers, <br /> performance data,and timeline or ren- ' ,e contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEO Annnat Operation anti Mninlenanre Report Form Rev.6/2022 <br />