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State of Oregon Department of Environmental Quality / 7-)10 7//-//V <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: TYLER & MEGAN FAIRBANK 503-302-8891 <br /> Phone: <br /> Site Address: 6898 Cascade Hwy NE 061 E3OB 01300 <br /> Parcel#: <br /> City: Silverton Marion <br /> County: <br /> Permit#: 555-15-001600 4/6/15 <br /> Start up date if 1st year in use: <br /> System Model#: AX20-RT System Serial#: 130340 <br /> Report Year: 2025 /�1 Date of Service Performed: 10/28/2025 <br /> Email Address: fairbant@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> ❑ 0 Was maintenance performed as required by septic system rules and the manufacturer? <br /> i] 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 /> ❑ i] Sewage backup into plumbing fixtures? <br /> If you answered"Yes"on the last four questions,was a repair permit obtained? If not,explain: <br /> [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): Brandon Pitts - A & B Septic Service <br /> 'Certification#: M 715 *Certification Expiration: 5/20/2028 <br /> ('This line only can be filled out and photocopied.) <br /> Original Signature: 131AnA711.2"4-1 Date: 12/31/2025 <br /> Note:Maintenance providers must maintain accurate records of their maintenance contracts, customers, <br /> performance data, and timelines for renewing the contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEO Annual Operation arid Mantenance Report Ponn Rev 612022 <br />