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State of Oregon Department of Environmental Quality _s& y9 /#/N6 <br /> Annual Operation and Maintenance <br /> ,DEQ Report Form <br /> General Information (Complete ALL information) <br /> grope y Owner: RS DUNCAN LLC Phone: 503-390-4999 <br /> 115 SHORT AVE. W Parcel#: 105E02DA01500 <br /> Site Address: <br /> City: DETROIT county Marion <br /> Permit#: 555-21-010093 Start up date if 1st year in use: 11/17/23 <br /> System Model#: AX2ON System Serial#: 150697 <br /> Report Year: <br /> 2025 Date of Service Perfo med: 10/16/25 <br /> Email Address: RICH@RICHDUNCANCONSTRUCTION.COM <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 /> Q ❑ 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 /> 0 Q 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 /> 1 cenify that-thisreport 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 can be fill d oiit1and pho • ••ed.) <br /> �� 12/31/2025 <br /> Original Signature: - Date: <br /> Note: Maintenance provider ••.auLntai accurate records of th it maintenance contracts, customers, <br /> performance•_ =, - • timelines fo'*- ing the contracts. Th—.- records must be available for inspection upon <br /> request by the agency per OAR 340-0 • 30(24). <br /> OLD Annual Operation and Maintenance Reece Form "` " " <br />