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555-2D-OWLfl3TIQ' <br /> State of Oregon Department of Environmental rituality <br /> 1 <br /> Annual Operation and Maintenance <br /> Report Form <br /> e,gd 2 c73 <br /> General Information (Complete ALL Information) <br /> Properly owner GRAHAM MUNSELL Phone: 503-910-6672 <br /> Site Address: 4387 WINDY WAY NE Parcel 071 E06000900 <br /> City: SILVERTON County: Marion <br /> Permit u 555-15-007572-SEP Start up date 1st year in use: 10/17/19 <br /> System Model it: AX2ORT system serial#: 140451 <br /> Report Year 2025 Date or service Performed: 6/4/2025 <br /> Email Address: gkmunsell@yahoo.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 /> x❑ 0 Is the system operating in accordance with the agent-approved design specifications? <br /> ❑ MI Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ MI Is the system failing? <br /> ❑ ® 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 /> "WE ARE NO LONGER THE O&M PROVIDER'•• <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 e: M 587 •Certification Expiration: 3/28/2026 <br /> ('This line only can be filled out and <br /> Original Signature: Date: 12/31I2025 <br /> Note:Maintenance providers must maintain accurate records of their maintenance contracts,customers, <br /> • performance data,and timelines for renewing the contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br />