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(1 000733- JNt <br /> State of Oregon Department of Environmental Quality <br /> SA Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> PropertyOwner: BGRS RELOCATION INC Phone: 480-788-6533 <br /> 1399 TWIN HILLS DR. SE 555-05-00291 <br /> Site Address: Parcel#: <br /> City: JEFFERSON county: Marion <br /> Permit#: 1 Z-O21 O2 Start up date if 1st year in use: NA <br /> System Model#: AX2ORT-1 B System serial#: 125697 <br /> Report Year: 2025 Date of Service Performed: 9/22/2025 <br /> Email Address: BOBBY.EDMONDSON@SIRVA.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> LJ 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 /> O El Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ I Is the system failing? <br /> ❑ ❑� Discharge of sewage to the ground surface? <br /> ❑ I] 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 - ation Expiration: 3/28/2026 <br /> ('This line only can be • ed • t and p <br /> 12/31/2025 <br /> Original Signature: -- - Date: <br /> Note: Maintenance pr• iders ust aintain accu -te records of their maintenance contracts,customers, <br /> performance data,and ti may. renew•• • e contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEG Annual Ooeration aMU Veal, anerne Report,am Rev iid.122 <br />