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/Nr )/ <br /> State of Oregon Department of Environmental Quality <br /> S4Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: Jon Jost Phone: 503-891-1244 <br /> 140 Lake Crest Dr 105E02AD02400 <br /> Site Address: Parcel#: <br /> Detroit Marion <br /> City: County: <br /> Permit#: 10-04622 Start up date if 1st year in use: NA <br /> System Model#: AX2ORT System Serial#: 146878 <br /> Report Year: 2025 Date of service Performed: 12/18/2025 <br /> Email Address: jondjost@gmaii.cor11 <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 /> li ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> O El Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ 0 Is the system failing? <br /> ❑ Q 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 /> t 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: 3/28/26 <br /> ('This line only cant and p Mn vied <br /> Original Signatu Date: 12/31/2025 <br /> Note: Maintenance p • ers aintain accur e records of their maintenance contracts, customers, <br /> performance data,and time for renewing the ntracts. These records must be available for inspection upon <br /> request by the agency per OAR 340- <br /> DEC)Annual Ope'atio land Msi n:enance Reran Eorrr <br /> Re• "2Q22 <br />