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d <br /> State of Oregon Department of Environmental Quality a2i/ UD//v/ / 1/ <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: MARGIT EISENHUT Phone: 503-580-8009 <br /> Site Address: 6792 MACLEAY RD SE Parcel# 082W03B005600 <br /> City. SALEM county: Marion <br /> 555-22-010479-PRMT Start up date if 1st year in use: 06/29/2023 <br /> Permit#: <br /> System Model#: AX2ON System Serial#: 150265 <br /> Report Year: 2025 Date of Service Performed: 5/23/2025 <br /> Email Address: DVRA.EISENHUT@YAHOO.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> Q ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> a ❑ 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 /> ❑ El Is the system failing? <br /> ❑ • Discharge of sewage to the ground surface? <br /> ❑ It 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#: *Certification 587 "Certification Expiration: 3/28/2026 <br /> ('This line only can be ed t and photocopi d.) <br /> 12/31/2025 <br /> Original Signature: Date: <br /> Note: Maintenance provide must mainta accurate reco s of their maintenance contracts, customers, <br /> performance data,and timeli renewi contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24 . <br /> DEQ Annual Operation and Maintenance Report Farr 4ev.G/2022 <br />