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,23-0/47P A/4/ <br /> /'g, State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: DAMA CURTRIGHT, 330 TRIANGLE LLC Phone: 503-937-1904 <br /> s Address: 4087 WINTERCREEK RD SE Parcel#: 09271901300 <br /> city: JEFFERSON Marion <br /> County: <br /> Permit#: 555-21-011989 8/22/22 <br /> Start up date if 1st year in use: <br /> System Model#: AX2ORT System Serial#: LOGO <br /> Report Year: 2025 Date of Service Performed: 9/17/2025 <br /> Email Address: DAMACURTRIGHT@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> x❑ 0 Was maintenance performed as required by septic system rules and the manufacturer? <br /> x❑ 0 Is the system operating in accordance with the agent-approved design specifications? <br /> ❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ g Is the system failing? <br /> El Ig Discharge of sewage to the ground surface? <br /> ❑ It Discharge of sewage to drain tiles or surface waters? <br /> ❑ Ei 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 '7 'Certification Expiration: 3/28/2026 <br /> ('This line only can b- lied • t and photocopied.) <br /> /I � 12/31/2025 <br /> Original Signature .t./l���u . Date: <br /> Note: Maintenance provid- ryn�y st maintain accura - records of their maintenance contracts, customers, <br /> performance data, and ti ell'*-- for renewing the co.tracts. These records must be available for inspection upon <br /> request by the agency per •AR 340-071-0130(24). <br /> OLO Annual Operation and Maimenance Rep. _ Rev 6:2022 <br />