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State of Oregon Department of Environmental Duality 073— 01)M2°— / 0/ <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: DANIEL ESTACIO Phone: 503-581-0441 <br /> 270 CORDON RD. NE Parcel#: 072W29D01600 <br /> Site Address: <br /> City: SALEM County: Marion <br /> Permit# 555-20-005928 Start up date it 1st year in use. 2/28/22 <br /> System Model#: <br /> AX2ORT System Serial#: 145024 <br /> Report Year: 2025 Date of Service Performed: 8/27/2025 <br /> Email Address: NURSERY@TERRAGARDENS.NET <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 /> 0 Is the system operating in accordance with the agent-approved design specifications? <br /> Q ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> , © Is the system failing? <br /> 0 • Discharge of sewage to the ground surface? <br /> ❑ I 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 Name(please print): Cory Morgan - A & B Septic Service <br /> 'Certification#: M� *Certification Expiration: 3/28/2026 <br /> __(This Nee any-can • u ed <br /> �1an Date: 12/31/2025 <br /> Original Signature. �� <br /> Note: Maintenance prow•ere mu- mainta -ccurate r-cords of their maintenance contracts, customers, <br /> performance data,and ti r Ines f•r renewing t'r •ntr cts. These records must be available for inspection upon <br /> request by the agency per OA- 40-071-0130(24). <br /> DEL, .rc:;Lon fl :,ancc r v, _.m .ev r,2022 <br />