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State of Oregon Department of Environmental Quality /7 Oc1d7Ys /I/ Q <br /> ri1 Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Propertyowner: RYAN GOEHRING Phone: 503-508-9851 <br /> Site Address: 8033 Mill Creek Rd Parcel#: 082W26D003100 <br /> city: Aumsville County: Marion <br /> Permit#: 08-05113 Start up date if 1st year in use: NA <br /> System Model#: AX2O-1 B System Serial#: 114660 <br /> Report Year: 2025 Date of Service Performed: 2/27/2025 <br /> Email Address: AGOEHRING@gmail.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 /> ❑ 1.1 Is the system failing? <br /> ❑ El Discharge of sewage to the ground surface? <br /> ❑ UI Discharge of sewage to drain tiles or surface waters? <br /> ❑ Q 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: 3/28/26 <br /> (*This line only can be filled out and photocopi=d.) <br /> Original Sig_natuce:. <br /> �► Date: 12/31/2025 <br /> Note: Maintenance providers mai fain ace,rate records of their maintenance contracts,customers, <br /> performance data,and timelin-- or ren-wing th>contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071 : 30(2.). <br /> Dtr AlnIntia rteintion andf 4' nenar[a kepar .:Reim Rev b2022 <br />