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,/`¢- State of Oregon Department of Environmental Quality /" v50 -7/1 / <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: Steve Flett Phone: 503-743-2456 <br /> Site Address: 6039 Pear Tree Lane SE Parcel#: 082W21 B001501 <br /> City: Salem County Marion <br /> Permit#: 07-06339 Start up date if 1st year in use: NA <br /> System Model#. <br /> AX2ON 1 B System Serial#: 112605 <br /> Report Year: <br /> 2025 Date of Service Performed: 5/14/2025 <br /> Email Address: SFLETT1022@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not preftll and photocopy checkboxes) <br /> Yes No <br /> O 0 Was maintenance performed as required by septic system rules and the manufacturer? <br /> Et ❑ 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 /> 0 II Is the system failing? <br /> \� <br /> 1�I�\ <br /> Discharge of sewage to the ground surface? <br /> tEl <br /> ❑�• <br /> Q 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 587 *Certification Expiration: 3/28/2026 <br /> (*This line only can be fed ooand led.) <br /> --m 12/31/2025 <br /> Original Signature: Date: <br /> Note: Maintenance provi rs mu t mai,.ain accurate re •rds of their maintenance contracts,customers, <br /> performance data, and time or renewing --• r. --. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEQ Annual Operation and Maintecance Report form Rev.6/2022 <br />