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1/41 <br /> State of Oregon Department of Environmental Quality au- 1 ' I Itd <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> C 5c. 1-US21a5 <br /> General Information (Complete ALL Information) <br /> Property Owner: CARL & LAURIE GRETZINGER Phone: 503-509-9322 <br /> Site Address: 6223 MILL CREEK RD. Parcel#: 082W28D001900 <br /> city: TURNER county: MARION <br /> Permit#: UNKNOWN Start up date if 1st year in use: 7/3/25 <br /> System Model#: AX2ORT System Serial#: LOGO <br /> Report Year: 2025 Date of Service Performed: <br /> Email Address: CGRETZINGER@MSN.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> Q ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> x❑ ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> Q ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ IN Is the system failing? <br /> ❑ 0 Discharge of sewage to the ground surface? <br /> ❑ 0 Discharge of sewage to drain tiles or surface waters? <br /> ❑ 0 Sewage backup into plumbing fixtures? <br /> If you answered"Yes"on the last four questions,was a repair permit obtained? If not,explain: <br /> "'" START UP DONE AFTER 7/1/2025 "' <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 be I out and photo . .'ed.) A <br /> � 12/31/2025 <br /> Original Signature: Date: <br /> Note: Maintenance provi•-Ist -intain accurate -cords of their maintenance contracts, customers, <br /> performance data, and tim- for rene••'•• the contr cts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130( . <br /> oEO Annual Operaoon and Maintenance Report Form Rev 6/2022 <br />