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fiv <br /> State of Oregon Department of Environmental Duality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: Oleg Foksha Phone: 503-999-8068 <br /> Site Address: 9431 Donald Ln SE Parcel#: 092W06B 03800 <br /> City- Turner County: Marion <br /> Permit#: 555-23-003963-PRMT Start up date if 1st year in use: 03/01/2024 <br /> System Model#: AX2ORT System Serial#: 147843 <br /> Report Year: 2025 Date of Service Performed: 11/21/2025 <br /> Email Address: FOKSHAHOMES@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> l] ❑ 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 /> x❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ l] Is the system failing? <br /> El • Discharge of sewage to the ground surface? <br /> • El 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 beJ�rinut an piertr) —— <br /> Original Signature: , Date: 12/31/2025 <br /> Note: Maintenance provi ust maintain accurate records of eir maintenance contracts,customers, <br /> performance data, and time Ines for re . se records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEC Annual Operation and Maintenance Report For'rn Rev 6/2022 <br />