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/- g20739-/NV <br /> .f 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: MAX CUEVAS Phone: 503-383-6018 <br /> 8825 HOLMQUIST ST. SE 081W31C01900 <br /> Site Address: Parcel#: <br /> City: AUMSVILLE county: Marion <br /> Permit#: 555-1 5-00 1 1 56 Start up date if 1st year in use: 9/18/15 <br /> System Model#: AX25RT System Serial it: 131707 <br /> Report Year: 2025 Date of Service Performed: 8/7/2025 <br /> Email Address: maxjcuevas@9mail.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 /> a ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ Q Is the system failing? <br /> ❑ in Discharge of sewage to the ground surface? <br /> ❑ Q Discharge of sewage to drain tiles or surface waters? <br /> ❑ El 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-tcertify-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 be fill=. ID1 t and photoco•ed.) <br /> Original Signature: . s`` , > Date: 1 Z/31/2025 <br /> _Plate:-Malnlance provide - mu \ aintain accurate -cords of their maintenance contracts, customers, <br /> performance data,and timeline - -newing the contr.cts. These records must be available for inspection upon <br /> request by the agency per OAR 340-07 5 30(24). <br /> DEC)Annual Operation and Maintenance Report Form Rev.6/2022 <br />