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if,-ttAR �NQ.R <br /> State of Oregon Department of Environmental Quality <br /> Silk Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: KIMBERLY NASSET Phone: 503-881-9537 <br /> Site Address: 1185 CORDON RD. NE Parcel#: 072W2OCA00800 <br /> City. SALEM county: Marion <br /> 07-02496 N/A <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: DELTA WHITE WATER System Serial#: <br /> DELTA <br /> Report Year: 2025 Date of Service Performed: 8/27/2025 <br /> Email Address: DONSATTERCONSTRUCTION@COMCAST.NET <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 /> E ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> I] El Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ I] Is the system failing? <br /> ❑ Q Discharge of sewage to the ground surface? <br /> ❑ El Discharge of sewage to drain tiles or surface waters? <br /> ❑ IN Sewage backup into plumbing fixtures? <br /> If you answered"Yes'on the last four questions,was a repair permit obtained? If not,explain: <br /> 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 ertification "'ration: 3/28/2026 <br /> (This line only can be ' . . t and photo...'-.,) <br /> Original Signature: r a Date: 1 Z/31/ZOZS <br /> Note: Maintenance providers m st m thin acc ate records 4f their maintenance contracts,customers, <br /> performance data,and timelines or re -wing the ..ntracts. T ese records must be available for inspection upon <br /> request by the agency per OAR r -0130(24). <br /> Didu Annual Operation and Mamlenance Report Form Rev.62022 <br />