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_er - State of Oregon Department of Environmental Quality /7- D07 V'D l/A <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: JACKIE EBERLY Phone: 971409-6327 <br /> 9691 HIGUERA LN. Parcel if <br /> R345064 <br /> Site Address: <br /> City: AURORA county: Marion <br /> Permit it: Start Start up date it 1st year in use: NA <br /> System Model*: AX20 RT System Serial#. 129113 <br /> Report Year: 2025 Date of Service Performed: 5/29/2025 <br /> Email Address: jackieeberly@funo.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> z❑ 0 Was maintenance performed as required by septic system roles and the manufacturer? <br /> a ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> x❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ IB Is the system failing? <br /> ❑ Iil Discharge of sewage to the ground surface? <br /> ❑ El Discharge of sewage to drain tiles or surface waters? <br /> ❑ IN 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 certify thatthls 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 ff. M 587 "Certification Expiration: 3/28/2026 <br /> ("This line only can b filla: out i • <br /> 12/31/2025 <br /> Original Signature: Date: <br /> Note: Maintenance provide mus main -'n accurate rer ords of their maintenance contracts,customers, <br /> performance data,and timeli renew' •• - s. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEQ Annual Operation and Maintenance Report Form Rev 6,2022 <br />