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State of Oregon Department of Environmental Quality�" V ?/VHy <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> RICH KANSKY 503-930-1922 <br /> Property Owner: Phone: <br /> Site Address: 320 JANICE CT Parcel#: 105E02DA06300 <br /> City. DETROIT county: Marion <br /> 555-16-006681-SEP 07/17/2024 <br /> Permit#: Startup date if 1st year in use: <br /> System Model#: AX2ORT System Serial#: 149221 <br /> Report Year: 2025 Date of Service Performed: 8/6/2025 <br /> Email Address: RICH@GREENACRESLANDSCAPEINC.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 /> x❑ ❑ 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 /> ❑ MI Is the system failing? <br /> ❑ Q Discharge of sewage to the ground surface? <br /> ❑ IN 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 /> 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 fil .d tilt and pho ocopied.) <br /> Original Signatur:. _ .-,. t Date: 12/31/2025 <br /> _sNote: Maintenance pro 'de st maintain acc• -te records of their maintenance contracts,customers, <br /> performance data, and ti - 'n'. •r renewing the ontracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-0 -. . 4). <br /> DCo Annual operation and `deafer an;c Report I onn Rev 612022 <br />