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State of Oregon Department of Environmental Quality / 77— /4/6J <br /> �31 Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: CHRIS & BRITTANY KLEIN Phone: 503-510-1080 <br /> Site Address: 11522 SHEBA LN. SE Parcel#: 081 W32A 00200 <br /> City- AUMSVILLE County: Marion <br /> Permit#: 555-16-006465-SEP Start up date if 1st year in use: 9/5/17 <br /> System Model#: AX2ORT System Serial#: 136024 <br /> Report Year: 2025 Date of Service Performed: 10/28/2025 <br /> Email Address: Chris@cascadefloors.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> x❑ ❑ 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 /> x❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ❑� Is the system failing? <br /> ❑ II 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 /> 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 dreetand photo d) <br /> - Date: 12/31/2025 <br /> Original Signatu <br /> Note:Maintenance provider mu aintain accurate cords of their maintenance contracts,customers, <br /> performance data,and timelin newing the cont s. These records must be available for inspection upon <br /> request by the agency per OAR 340- -0130(24). <br /> Dr Q Annual operation and Maintenance Report Form Rev 612022 <br />