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62132-C00c\\D-'T }J D. <br /> State of Oregon Department of Environmental Quality <br /> S4 Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner STEVE PERLENFEIN Phone: 541-979-6377 <br /> Site Address: 375 JANICE CT Parcel#: 105E02DA07000 <br /> city: DETROIT coons: Marion <br /> Permit#: 555-23-005237 Start up date if 1st year in use: 02 26/2024 <br /> System Model#: AX2ORT System Serial#: MVP <br /> Report Year: 2025 Date of Service Performed: 7/25/2025 <br /> Email Address: SRPERLENFEIN@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> x❑ ❑ 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 /> x❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ In Is the system failing? <br /> ❑ Q 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 /> 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 it °7 *Certification Expiration: 3/28/2026 <br /> ('This line only can la filled • t and • copied.) <br /> Original Signature: .. I /d_ ,�il�_ Date: 1 Z/31/2025 <br /> Note: Maintenance providers mu! aintain a urate ecords of their maintenance contracts, customers, <br /> performance data, and timelin- f• ewing the con acts. These records must be available for inspection upon <br /> request by the agency per OAR : •-071-. • 24). <br /> DLG Annual Operation and Mdpirenance Repo i dorm Rev 62 J22 <br />