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State of Oregon Department of Environmental Quality <br /> wig <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information(Complete ALL information) <br /> PAUL THOMPSON 503-910-3878 <br /> Property Owner: Phone: <br /> Site Address: 11299 PHANTOM LN, Parcel It: 091 E14A000800 <br /> Dry: STAYTON County: Marion <br /> Permit#: 555-16-005862-SEP start up date if 1st year in use: 4/18/2017 <br /> System Model#: PRESSURE DISTRIBUTION systemSeral#: N/A <br /> Report Year: 2025 Date of Service PeMnled: 4/22/2025 <br /> Email Address: PAULTHOMPSONAUCTIONEER@YAHOO.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> 0 0 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 /> 0 0 Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ NI Is the system failing? <br /> ❑ ® Discharge of sewage to the ground surface? <br /> 0 ® Discharge of sewage to drain tiles or surface waters? <br /> ❑ II Sewage backup into plumbing fixtures? <br /> if you answered"Ye 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#: 687 *Certification Expiration: 3128/2026 <br /> ('This line only can •: fil-• ou • •lichw ..'— <br /> Original Signature: al it . Date: 12/31/2025 <br /> ar v. • <br /> Note:Maintenance provider- ust main in accurate records of their maintenance contracts,customers, <br /> performance data,and ti e -a for rene 'ng the contracts. These records must be available for inspection upon <br /> request by the agency pe • R 340-071 1130(24). <br /> DEQ Armuoi Q(M1anon and Mar rlcna a Rerp+ PT? Htv 6g022 <br />