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State of Oregon Department of Environmental Quality C� ' !/V //c-C —/4/i y" <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL Information) <br /> Property Owner: DAN EDWARDS 503-510-5203 <br /> Phone: <br /> Site Address: 110 TUMBLE ST N 105E01BC04300 <br /> Parcel#: <br /> City: DETROIT Marion <br /> County: <br /> Permit#: 555-21-004364 07/24/2023 <br /> Startup date if 1st year in use: <br /> System Model it: PRESSURE DISTRIBUTION N/A <br /> System Serial#: <br /> Report Year: 2025 1/22/2025 <br /> Date of Service Performed: <br /> Email Address: UNKNOWN <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> Q El Was maintenance performed as required by septic system rules and the manufacturer? <br /> El ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> I] ❑ 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 /> ❑ I] 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 <br /> rrr,,,Name(please print): Cory Morgan - A & B Septic Service <br /> 'Certification#: - *Certification Expiration: 3/28/2026 <br /> ('This line only can be ed out n•..., . <br /> Original Signature: <br /> IrIF Date: 12/31/2025 <br /> Note: Maintenance provide ust a stain accurate record- of their maintenance contracts, customers, <br /> performance data, and timeline ne '.r the contracts These records must be available for inspection upon <br /> request by the agency per OAR 340-071-013. . <br /> DEO Annua!Operation are Maintenance Repnu Form Rev 6:2022 <br />