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-e-rtt& State of Oregon Department of Environmental Quality 0.37 6O//) 7- // V lX 7 <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: HELEN LARA Phone: 971-599-9501 <br /> 23665 N. FORK RD. SE 092E17AB00100 <br /> Site Address: Parcel it <br /> City' LYONS county: Marion <br /> Permit#: 555-19-007412-PRMT Start up date if 1st year in use: NA <br /> PRESSURE DISTRIBUTION y NA <br /> System Model#: System Serial#: <br /> Report Year: 2025 Date of Service Performed: 12/03/2025 <br /> Email Address: HELENLARA@WVI.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> I] ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> E ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> I] El Is the system currently under a service contract with a certified maintenance provider? <br /> E I] Is the system failing? <br /> ❑ ❑� Discharge of sewage to the ground surface? <br /> ❑ I] Discharge of sewage to drain tiles or surface waters? <br /> ❑ I] Sewage backup into plumbing fixtures? <br /> If you answered"Yes"on the last four questions,was a repair permit obtained? If not,explain: <br /> icertify thatthis 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 :- lied'out and uy.. .-'. <br /> //(( _ 12/31/2025 <br /> Original Signatu e: Ar-1 a;-��VIL Date: <br /> Note: Maintenance provider r�l`k maintain a -cords of their maintenance contracts,customers, <br /> performance data,and timeline-Zy. en- ?=ay.. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DLO Annua:Operation and Ma ntenalice Report Form Rev.6/2022 <br />