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State of Oregon Department of Environmental Quality / fL o / t5U /A4 <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Propertyowner: KJK PROPERTIES, LLC Phone: 503-480-4976 <br /> Site Address: 13008 DOMINIC RD. Parcel#: 061W03A01200 <br /> City. MT. ANGEL County: Marion <br /> Permit#: 555-16-007289-SEP Start up date if 1st year in use: 10/27/17 <br /> System Model#: AX2ORT System Serial#: 136695 <br /> Report Year: 2025 Date of Service Performed: 11/12/2025 <br /> Email Address: kraemerkyle@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 /> ❑ ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> ID ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ El Is the system failing? <br /> ❑ I] Discharge of sewage to the ground surface? <br /> ❑ IN Discharge of sewage to drain tiles or surface waters? <br /> ❑ Q 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 be €do .and espied.) <br /> Original Signature: Date: 12/31/2025 <br /> Note:Maintenance provid rs u maintain a rate records of their maintenance contracts, customers, <br /> performance data, and tim ins renewing t contracts. These records must be available for inspection upon <br /> request by the agency per 0 0-071-013 4). <br /> DEO Annual Operation aid Maintenance Report Form Rev.62022 <br />