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-r'"-Q, State of Oregon Department of Environmental Duality 02c2l acZ W5—/' • W <br /> SAAnnual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Propertyowner: TYLER FREDINGBURG 503-932-1083 <br /> Phone: <br /> Site Address: 325 JANICE CT. 105E02DA07500 <br /> Parcel#: <br /> City: DETROIT Marion <br /> County: <br /> Permit#: 555-21-003613-PRMT N/A <br /> Start up date if 1st year in use: <br /> AX2ORT 145046 System Model#: <br /> System Serial#: <br /> Report Year: 2025 10/1/2025 <br /> Date of Service Performed: <br /> Email Address: 325JANICE@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 /> I] ❑ 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 /> ❑ ❑� Is the system failing? <br /> ❑ MI Discharge of sewage to the ground surface? <br /> ❑ I• Discharge of sewage to drain tiles or surface waters? <br /> ❑ II 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 ut and p copied.) <br /> Original signature _ Date: 12/31/2025 <br /> Note: Maintenance pro t maintain ac re rds of their maintenance contracts,customers, <br /> performance data,and tim- renewing the contract These records must be available for inspection upon <br /> request by the agency per OAR 340- 71-0130(24). <br />