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I/- 000755— l k6? <br /> - State of Oregon Department of Environmental Quality <br /> � 31 Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> PropertyOwner: DEAN & MELISSA CLEARY Phone: 503-559-1187 <br /> Site Address: 8081 LITTLE RD. SE Parcel#: 082W3500900 <br /> City: County:County: Marion <br /> Permit#: 555-15-006134 Start up date if 1st year in use: 5/1 Z/16 <br /> System Model#: AX2ORT system Serial s: 133076 <br /> Report Year: 2025 Date of Service Performed: 10/22/2025 <br /> Email Address: MELISSA_CLEARY@OUTLOOK.COM <br /> Onsite wastewater treatment system status: (Do not preftll and photocopy checkboxes) <br /> Yes No <br /> Q ❑ 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 /> in ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ❑] Is the system failing? <br /> ❑ Q Discharge of sewage to the ground surface? <br /> ❑ Q 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: 3/28/2026 <br /> (*This line only can b Iled o t and h o ie .) <br /> Original Sign • Date: 12/31/2025 <br /> Note: Maintenance provider ust 'ntain ac urate records of their maintenance contracts,customers, <br /> performance data,and timelines o renev4 contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340- -u s0(24). <br /> DEC Annual Dinerstein and Maintenance Reya'I Farr. Rev 6:2022 <br />