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State of Oregon Department of Environmental Quality (94 CASCA j <br /> Annual Operation and Maintenance <br /> riga <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: DONNA PETERS Phone: 503-581-9894 <br /> 992 IVA LN NE 072W20D01300 <br /> Site Address: Parcel#: <br /> City: SALEM county: Marion <br /> Permit#: 555-22-003959-PRMT Start up date if 1 st year in use: 02/28/2023 <br /> System Model#: AX2ORT System Serial#: MVP <br /> Report Year: 2025 Date of Service Performed: 5/30/2025 <br /> Email Address: DLPCHOWDER@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> '❑ ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> x❑ El Is the system operating in accordance with the agent-approved design specifications? <br /> I] ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ I] Is the system failing? <br /> ❑ IU Discharge of sewage to the ground surface? <br /> ❑ I] 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 rep is complete and accurate to the best of my knowledge. I understand that falsification of this <br /> report is grounds for rev tion of my certification and/or civil penalties. <br /> `Maintenance Provider Name(ple'e,print): Cory Morgan - A & B Septic Service <br /> `Certification#: 587 `Certification Expiration: 3/28/2026 <br /> (`This line only be filled o otocopied.) <br /> Original Signe • Date: <br /> 12/31/2025 <br /> Note: Maintenance provi ers us maintain a urate records of their maintenance contracts, customers, <br /> performance data, and time es for newing t contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-07 - <br /> DEQ Annual opentm and Maintenance Report Ford Rev 6.2022 <br />