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,�'�2 State of Oregon Department of Environmental Quality <br /> .2210029 /N& <br /> .44 <br /> Annual Operation and Maintenance <br /> rill <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: NANCY GUINN Phone: 503-508-8231 <br /> Site Address: 8725 W STAYTON RD. SE Parcel#: 082W36C 00200 <br /> City. AUMSVILLE County: Marion <br /> Permit St: Start up date it 1st year in use: NA <br /> System Model it SINGULAIR System se al#: 2X290238 <br /> Report Year: <br /> 2025 Date of Service Performed: 9/23/2025 <br /> Email Address: nliguinn3@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> O 0 Was maintenance performed as required by septic system rules and the manufacturer? <br /> i] ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> Q 0 Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ® Is the system failing? <br /> 0 i] Discharge of sewage to the ground surface? <br /> ❑ I] Discharge of sewage to drain tiles or surface waters? <br /> D © 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 befdk�ou(and photoco•'ed) <br /> I_'( 41. <br /> 12/31/2025 <br /> Original Signatu dON <br /> er Date:Note: Maintenance providers u t maa records of their maintenance contracts, customers, <br /> performance data,and timelines r reneg •ntracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEO Annual Operation and Maintenance Report Fern Rev.6120:2 <br />