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.,- State of Oregon Department of Environmental Quality 02(5—(/O.5j5 /" ' `-r y <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: BILL FRITH Phone: 503-403-9504 <br /> Site Address: 9953 NORTH FORK LANE SE Parcel#: 093E02DD00800 <br /> City: County: <br /> County: Marion <br /> Permit#: 555-22-002725 Start up date if 1st year in use: 08/26/2024 <br /> System Model#: MICROFAST System serial#: 00050214833 <br /> Report Year: 2025 Date of Service Performed: 12/03/2025 <br /> Email Address: BILLFRITH@COMCAST.NET <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> x❑ ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> O ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> 0 ❑ 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 /> ❑ © 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- . -d o and pho •copied.) <br /> o . - teas 1 I Date: 12/31/2025 <br /> Note: Maintenance provide t mai cords of their maintenance contracts, customers, <br /> performance data, and timelines or renewin -cts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEQ Annual Operation and Maintenance Report Form Rev.E/2022 <br />