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I�oad��N-iND <br /> State of Oregon Department of Environmental Quality <br /> �31 Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL Information) <br /> Property owner: KIM CLOVIS Phone: 503-873-8031 <br /> Site Address: 4066 Edison Rd Parcel#: 071W02C002900 <br /> City: Silverton County: Marion <br /> Permit#: 06-02934 Start up date if 1st year in use: NA <br /> System Model#. AX20-1 A system serial#. 106685 <br /> Report Year: 2025 Date of service Performed: 3/14/2025 <br /> Email Address: tSa.rye@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> -❑ -❑ -Yv`asmaiMenance 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 /> x❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ in Is the system failing? <br /> ❑ 0 Discharge of sewage to the ground surface? <br /> ❑ I. 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: 3/28/26 <br /> ('This line only can beedbgt and photoco•ied.) <br /> Original Signature: . � ' � I Date: 12/31/2025 <br /> enance providers mu ••a tam accurate r- ords of their maintenance contracts, customers, <br /> performance data, and timelines for re - -m the cont - ts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130 . <br /> ci _ i one atn v i a re�ai u.-., m Rev b2022 <br />