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\a\ t\b8\ tt)&Q <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> sin <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: DANIEL NUTTBROCK Phone: 503-932-4804 <br /> 7093 CONIFER ST. NE 072W22D00900 <br /> Site Address: Parcel#: <br /> City: SALEM County: Marion <br /> 555-18-007743 12/5/18 <br /> Permit#: Startup date if 1st year in use: <br /> System Model#: AX2ON System Serial#: 138851 <br /> Report Year: 2025 Date of Service Performed: 6/9/2025 <br /> Email Address: DLNUTTBROCK@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> i - 0- vvas 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 /> x❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ❑� Is the system failing? <br /> ❑ ❑� Discharge of sewage to the ground surface? <br /> ❑ Q 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 /> 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 5 - - I *Certification Ex ration /28/2026 <br /> ('This line only can led out and photocopied.) <br /> Original Signatur : `� <br /> - Date: 12/31/2025 <br /> Note: Maintenance provid- -t maintain ac rate records o their maintenance contracts,customers, <br /> performance data,and tim- .r renewing the tracts. Th se records must be available for inspection upon <br /> request by the agency per 0 - • 0-071-0130(24). <br /> DEO Annual Operation and Maintenance Report roan Rev 62022 <br />