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/ State of Oregon Deparbnent of Environmental Quality D // / "`/ <br /> nAnnual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: VICTOR & KAREN KINTZ Phone: 503-509-8277 <br /> Site Address: 190 BUTTE ST N Parcel#: 105E01BC05500 <br /> City. DETROIT County: Marion <br /> 555-22-004268 Start up date if 1st Y ear in use: 07/24/2023 <br /> Permit#: <br /> System Model#: AX20RTN-1 B/30 System Serial#: 147063 <br /> Report Year: 2025 Date of Service Performed: 7/25/2025 <br /> Email Address: VKINTZ@GMAIL.COM / KTWO@WVI.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> x❑ ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> O ❑ 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 /> O MI Is the system failing? <br /> ❑ 0 Discharge of sewage to the ground surface? <br /> ❑ • Discharge of sewage to drain tiles or surface waters? <br /> ❑ Q 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 •••tocopied.) <br /> Original Signetye: -, , �- Date: 12/31/2025 <br /> Note:Maintenance provid-rs st , aintain accu 4e records of their maintenance contracts,customers, <br /> performance data,and time fo renewing the c• tracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-+ 1-0130(24 <br /> DEC)Annual Operation and Maintenance Report Form Rev.6/2022 <br />