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State of Oregon Department of Environmental Quality /7(/OV7 J/,Q45 <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: VICTOR GROAH Phone: 559-686-6607 <br /> Site Address: <br /> 6967 QUARRY AVE. NE Parcel#: 061W26B001400 <br /> City. SILVERTON County: Marion <br /> Permit#: 12-06302 Start up date if 1st year in use: NA <br /> System Model#: AX2ONRT system Serial#: 126913 <br /> Report Year: 2025 Date of Service Performed: 12/02/2025 <br /> Email Address: VICGROAH@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> [] 0 Was maintenance performed as required by septic system rules and the manufacturer? <br /> I] ❑ 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 /> ❑ II Is the system failing? <br /> ❑ • Discharge of sewage to the ground surface? <br /> ❑ • Discharge of sewage to drain tiles or surface waters? <br /> ❑ ID 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: 3/28/2026 <br /> ('This line only can b-. Iled�lut an .(*This <br /> Original Signatu : ,q Date: 12/31/2025 <br /> r <br /> -- Note:Maintenance provi•-rs u• maintain accu -te records of their maintenance contracts,customers, <br /> performance data,and time r-s to - ewing the •ntracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-1 ). <br /> DEO Annual operation and Maintenance Report=onn Rev.6/2022 <br />