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2s- 0O/0/5 <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: MARVIE COLBY Phone: 503-509-6034 <br /> Site Address: 355 JANICE CT Parcel#: 105E02DA07200 <br /> City: DETROIT county: Marion <br /> 555-16-006690-SEP <br /> Permit#: Start up date if 1st year in use: N/A <br /> System Model#: AX2ORT System Serial#: 147663 <br /> Report Year: 2025 Date of Service Performed: 10/1/2025 <br /> Email Address: MARV@EVERGREENPLUMBING.TEAM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> '❑ ❑ 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 /> ❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ E Is the system failing? <br /> ❑ 0 Discharge of sewage to the ground surface? <br /> ❑ 0 Discharge of sewage to drain tiles or surface waters? <br /> ❑ El 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 be f out and photocopied) <br /> Original Signature: Date: 12/31/2025 <br /> Note: Maintenance providers ust aintain accur e records of their maintenance contracts, customers, <br /> performance data, and timeline- r r in the ntracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br />