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,2 4 7 q <br /> _Ertl State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> FIN <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: JEANYNE JAMES Phone: 503-407-1138 <br /> 11431 ROWENA AVE SE 092E16BC01200 <br /> Site Address: Parcel#: <br /> LYONS Marion <br /> City: County: <br /> Permit#: Start Start up date if 1st year in use: 9/30/21 <br /> System Model#: AX2ORT System Serial#: MVP <br /> Report Year: 2025 Date of service Performed: 12/03/2025 <br /> Email Address: KL82JAMES@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> El ❑ 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 /> *❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> — ❑ ❑� Is the system failing? <br /> ❑ • 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 /> 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 fil d out and photo <br /> Original Signature: Date: 12/31/2025 <br /> Note: Maintenance provider must intain accurate recor s of their maintenance contracts, customers, <br /> performance data, and timelines r r ewing the contra . These records must be available for inspection upon <br /> request by the agency per OAR 340-071- <br /> DE0 Annual Operation and Maintenance Report Form Rev 6'2022 <br />