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-erg State of Oregon Department of Environmental Quality <br /> 77- (0Z9 /// <br /> �31 Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: CADE HAGLER Phone: 503-989-7475 <br /> she Address: 321 3RD ST. Parcel#: 061 E15DC05200 <br /> City: SCOTTS MILLS County: Marion <br /> 07-07192 Start update if 1st ear in use: UNKNOWN <br /> Permit#: Y <br /> System Model#: DELTA WHITE WATER system Serial#: 07-07192 <br /> Report Year: <br /> 2025 Date of Service Performed: 8/5/2025 <br /> Email Address: CADEHAGLER@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> 0 ❑ Was maintenance performed as required by septic system rules 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 /> ❑ I] Is the system failing? <br /> ❑ IN Discharge of sewage to the ground surface? <br /> ❑ 19 Discharge of sewage to drain tiles or surface waters? <br /> ❑ 8 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 ca_nbe =r-T - • -•.- - <br /> -�_I//�� 12/31/2025 <br /> Original Signature: a�i� <br /> Date: <br /> Note: Maintenance prom st maintain accurate ecords of their maintenance contracts, customers, <br /> performance data,and time n-: •r renewing the cont =cis. These records must be available for inspection upon <br /> request by the agency per OAR 34r-: -0130(24). <br /> DEC annual Operation and Manlenance ReporI Form Rev.62022 <br />