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State of Oregon Department of Environmental Quality /7 OM //N <br /> w ! Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: TERRY GERMAN 541-912-3424 <br /> Phone: <br /> Site Address: 14092 PIPER ST. NE Parcel#: 041W02DCO2100 <br /> city: AURORA Marion <br /> County: <br /> Permit#: 11-01784 N/A <br /> Start up date if 1st year in use: <br /> SystemAX2ORT-1 B 123354 Model#: <br /> System Serial#: <br /> Report Year: 2025 8/18/2025 <br /> P Date of Service Performed: <br /> Email Address: BASSDEBJO@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> I] 0 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 /> I] El Is the system currently under a service contract with a certified maintenance provider? <br /> El © Is the system failing? <br /> ❑ ❑� Discharge of sewage to the ground surface? <br /> ❑ Q Discharge of sewage to drain tiles or surface waters? <br /> ❑ In 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 3/28/2026 <br /> "Certification Expiration: <br /> ("This line only be filled out and photo <br /> Original Sign_ Date: 12/31/2025 <br /> Note:Maintenance provi rs mu t ' tam accurate record f their maintenance contracts,customers, <br /> performance data, and tim ' es renewing S. 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 Form Rev 612022 <br />