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State of Oregon Department of Environmental Quality /7 690" 30— / <br /> vli Annual Operation and Maintenance <br /> Will <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner Robert Labrum Phone: 702-379-2491 <br /> Site Address: 5291 Concomly Rd NE Parcel#: 052W320000500 <br /> City: Gervais county: Marion <br /> Permit it: Start Start up date if 1st year in use: NA <br /> System Model n. AX2O-1 B system serial u. 112409 <br /> Report Year: 2025 Date of Service Performed: 9/22/2025 <br /> Email Address: rllablando@aol.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 /> Q ❑ 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 /> ❑ 0 Is the system failing? <br /> ❑ IN Discharge of sewage to the ground surface? <br /> ❑ • Discharge of sewage to drain tiles or surface waters? <br /> ❑ 0 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 (please print): Cory Morgan - A & B Septic Service <br /> `Certification it: *Certification 587 'Certification Expiration: 3/28/2026 <br /> (*This line only can led out and photocopied.) <br /> Original Signatu •� _ Date: <br /> 12/31/2025 <br /> Note: Maintenance providers u maintai acc rate records of their maintenance contracts, customers, <br /> performance data, and timeline or renew' g th contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-01 ). <br /> DEC/Annual Operation and Maintenance Report Font Rev.M2022 <br />