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State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: Richard Kline Phone: 503-917-9061 <br /> 12793 Brick Rd SE 092W24C000900 <br /> Site Address: Parcel#: <br /> city: Turner county: Marion <br /> Permit#: 09-03655 Start up date if 1st year in use: NA <br /> System Model#: AX20-1 B System Serial#: 122268 <br /> Report Year: 2025 Date of Service Performed: 4/4/2025 <br /> Email Address: rwk621@gmail.corn <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 /> ❑ Q Is the system failing? <br /> ❑ Q Discharge of sewage to the ground surface? <br /> ❑ Q Discharge of sewage to drain tiles or surface waters? <br /> ❑ l] 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 • •ed) — --- <br /> Original Signature __ Date: 12/31/2025 <br /> Note: Maintenance providers m tai accurate records of eir maintenance contracts,customers, <br /> performance data, and timelines fo enewi the contracts. The•e records must be available for inspection upon <br /> request by the agency per OAR 340-071-013 r ': . <br /> DEC)Annual Operation and Maintenance Report Form Rev 612f122 <br />