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-erg., State of Oregon Department of Environmental Quality �0/126-/ " y <br /> SAAnnual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> NORBERTO FLORES 503-391-7487 <br /> Property Owner: Phone: <br /> Site Address: 6932 LIBERTY RD S. Parcel#: 083W21 DCO16OO <br /> City. SALEM county: Marion <br /> 555-18-004729-PRMT 2/27/20 <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: AX2ORT System Serial#: 137165 <br /> Report Year: 2025 Date of Service Performed: 5/22/2025 <br /> Email Address: FLORESYGC@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> El ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> El ❑ 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 Is the system failing? <br /> ❑ ® Discharge of sewage to the ground surface? <br /> ❑ 0 Discharge of sewage to drain tiles or surface waters? <br /> ❑ Q 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 fi -d • t and •hotoco.;l-..) <br />-- --GriginalSignature: i es1� � Date: 12/31/ZOZ5 <br /> Al <br /> Note: Maintenance provid- ••-intain accurate records o their maintenance contracts,customers, <br /> performance data, and ti - -s for rene • -- • tract ese records must be available for inspection upon <br /> request by the agency per : •R 340-071-0130(24). <br /> DEO Annual Operation and Maintenance Report=orm Rev.6I2C22 <br />