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'02l¢- 013021R/12.-T1 C <br /> -/'g_ State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form \\ <br /> ab\-4. U(1 t &0\ L c <br /> General Information (Complete ALL information) <br /> Property Owner: SARA ROTH Phone: 503-409-2147 <br /> Site Address: 7782 WITZEL RD. SE Parcel#: 062W24D00500 <br /> City: TURNER County: MARION <br /> Permit#: 555-19-006596-PRMT Start up date if 1st year in use: 7/11/25 <br /> System Model#: AX2ORT System Serial#: LOGO <br /> Report Year: 2025 Date of Service Performed: <br /> Email Address: STYLISTSARAROTH@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> I] ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> x❑ El 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 /> ❑ ❑� Is the system failing? <br /> ❑ In Discharge of sewage to the ground surface? <br /> ❑ ❑� 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 /> *** 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 b• filledbyt a ( . • •pia ) <br /> Orhmal Signature Le) - ,A Date: 12/31/2025 <br /> Note: Maintenance provi•-rs mu t maintain - urate records •f their maintenance contracts,customers, <br /> performance data, and tim- ' es --'r renewing t contracts. T -se records must be available for inspection upon <br /> request by the agency per OAR 40-071-0130(24). <br /> DEQ Annuat operation ane ran ntenance Report Form Rem 62G22 <br />