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_erc, State of Oregon Department of Environmental Quality /7 vV 0964,-/ " 4P <br /> mil Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: TOM HILLYER Phone: 503-884-9547 <br /> Site Address: 7229 ORVILLE RD. S Parcel#: 084W26AB00302 <br /> City County:county: Marion <br /> Permit#: 06-02909 Start up date if 1st year in use: NA <br /> System Model#: AX20-1 A System Serial#: 107754 <br /> Report Year: 2025 Date of Service Performed: 10/6/2025 <br /> Email Address: VILAIPHONE1@YAHOO.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 /> 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 /> ❑ MI Is the system failing? <br /> ❑ ❑� Discharge of sewage to the ground surface? <br /> ❑ El 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 /> 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: 3/28/26 <br /> ('This line only can be filled out and •hva a•i-. <br /> Original Signature: a n Date: 12/31/2025 <br /> Note: Maintenance providers m .in accurate rec•rds of their maintenance contracts, customers, <br /> performance data, and timelines fo ng the contract- These records must be available for inspection upon <br /> request by the agency per OAR 340-071-013• ' <br /> _A! a Cperathni n n �.. .,Lit Ou 4ev .._ <br />