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,/`9_, State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> rile <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: PEGGY & SCOTT KRAMBUHL Phone: 503-984-2713 <br /> Site Address: 12018 HOLLY LN. SE Parcel if555-11-02980 <br /> City: JEFFERSON County: Marion <br /> 093 W 14D 00700 Start up date if 1st Y ear in use: 8/19/2011 <br /> Permit if:: <br /> System Model if: AX2ORT System Serial#. 123426 <br /> Report Year: 2025 - Date of Service Performed: 10/22/2025 <br /> Email Address: peggy.bones@gmail.com/SKRAMBUHL@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> Q ❑ 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 /> El ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> E Q Is the system failing? <br /> D 0 Discharge of sewage to the ground surface? <br /> O Q 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 /> leerily 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 . -- . : Cory Morgan - A & B Septic Service <br /> "Certification it: Mi "Certification Expiration: 3/28/2026 <br /> (*This line only can •• Iled out : d ph <br /> l Original Signature: 't 0 Al Ida Date: 12/31/2025 <br /> Note: Maintenance prov 7Tmainta % -cords of their maint= ance contracts,customers, <br /> performance data,and timelin- •e enewing the contracts. These re must be available for inspection upon <br /> request by the agency per OAR 340-07 -r - • <br /> DEO Annual Operation and PAantena ice Retaor -Din, Re, 612022 <br />