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\--1.-ocovaa-sQ <br /> -erg_ State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: BOB PANKRATZ Phone: 971-208-8900 <br /> Site Address: 1245 ANKENY HEIGHTS Parcel#: 093W04DC00100 <br /> City. SALEM county: Marion <br /> Permit#: 09-05618 Start up date it I st year in use: NA <br /> System Model*: AX2ON-1 A system Serial#: 105003 <br /> Report Year: 2025 Date of Service Performed: 9/2/2025 <br /> Email Address: BOB.PANKRATZ@YAHOO.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> O ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> Q ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> Q 0 Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ Q Is the system failing? <br /> O 0 Discharge of sewage to the ground surface? <br /> El Q Discharge of sewage to drain tiles or surface waters? <br /> ❑ II 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): Coy Morgan - A & B Septic Service <br /> M 587 - on, 3/28/2026 <br /> "Certification#: - - <br /> ("This line only can be outland p .''Wray �� " <br /> Original Signature: <br /> --- %l Vt Date: 12/31/2025 <br /> Note: Maintenance provide must m,intain a urate records of their aintenance contracts, customers, <br /> performance data,and timeli.-s for re -wing t - •ntracts. These r= •rds must be available for inspection upon <br /> request by the agency per OA- 340-0 1-0130(24). <br /> DEC;Annual Operation arid MameRlance Report Form Rev 6;2022 <br />