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State of Oregon Department of Environmental Quality I 7 ale / - <br /> 3t Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: JAKE DRINKWATER Phone: 503-509-0144 <br /> Site Address: 12405 PARRISH GAP RD. SE Parcel# O92W2OOOOO6O4 <br /> city: TURNER county: Marion <br /> 08-02820 NA <br /> Permit#: Start up date if 1st year in use: <br /> System Model#. AX2O-1 B System Serial#: 114175 <br /> Report Year: 2025 Date of Service Performed: 12/09/2025 <br /> Email Address: HAYMAKERJAKE@SBCGLOBAL.NET <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> n ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> • ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> Q ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ Q Is the system failing? <br /> ❑ I. Discharge of sewage to the ground surface? <br /> ❑ Q 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 filled oyt and photocopied.) <br /> ipta..�._ 12/31/2025 <br /> •n+ - • a ure: IJ Date: <br /> Note: Maintenance providers 'use main,:in accurat: records of their maintenance contracts,customers, <br /> performance data, and timelines for rene I•• th- •ntracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEC)Annual Operation and Maintenance Report r :or Rev.6,2022 <br />