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l `l -bob-l$U i C <br /> -rt.-Q. State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> will <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: SAMUEL PORTER Phone: 541-810-3882 <br /> 550 QUIET WAY SE 093W100000401 <br /> Site Address: Parcel#: <br /> City: SALEM county: Marion <br /> 06-05798 Start up date if 1st year in use: <br /> Permit#: NA <br /> System Model#: AX20-1 A System Serial#: 110110 <br /> Report Year: 2025 Date of Service Performed: 6/18/2025 <br /> Email Address: PORTERSAM@MAC.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 /> x❑ ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> El ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ i] Is the system failing? <br /> ❑ • Discharge of sewage to the ground surface? <br /> ❑ I] Discharge of sewage to drain tiles or surface waters? <br /> ❑ ❑fi 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 -- xpiration: 3/28/2026 <br /> (*This line only can be fill out and ph -d.) <br /> ofOriginal Signature: ,C5-... ` / Date: 12/31/2025 <br /> Note: Maintenance provide mus m-'main accurate re.•rds of their maintenance contracts, customers, <br /> performance data, and timelibeha foj ren-• 1• the contract . These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130( . <br /> DEO Annual JPeatmn and Maintenance Reno]I-and Rev.612022 <br />