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_trig State of Oregon Department of Environmental Quality v" v (/ r/6j <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: ROBERT KOTTRE Phone: 503-871-5620 <br /> Site Address: 155 3RD ST Parcel#: 105E02AD04500 <br /> City: DETROIT County: Marion <br /> Permit#: 21-004716 Start up date if 1st year in use: 06/23/2023 <br /> System Model#. AX20RT System Serial#: LOGO/MVP <br /> Report Year: 2025 Date of Service Performed. 5/21/2025 <br /> Email Address: R_KOTTRE@outlook.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> U ❑ 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 /> ❑ It Is the system failing? <br /> ❑ Q Discharge of sewage to the ground surface? <br /> El 0 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 /> 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 an. ••a .copied() <br /> Original Signatu -: Date: 12/31/2025 <br /> Note: Maintenance provid%=maintain accur - - •- - . enance contracts, customers, <br /> - .-•- - -, , • - - or recontracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEC Annt.a.OpelS.1(aelo Ma.ntondline LL'IM 2e: '3.2022 <br />