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-erg_ State of Oregon Department of Environmental Quality '— U O//5/ ^ / ts/ <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> PropertyOwner: RON MCKENZIE Phone: 503-881-0909 <br /> 251 KENS WAY S 093W04D01801 <br /> Site Address: Parcel#: <br /> City: SALEM county: Marion <br /> Permit#: 555-22-001573 Start up date if 1st year in use:AX <br /> 11/27/2023 <br /> System Model it: 20RT System Serial#: 147067 <br /> Report Year: 2025 Date of Service Performed: 9/2/2025 <br /> Email Address: RSAPROPERTIES@Iive.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> g ❑- Was-maintenance performed as required by septic system rules and the manufacturer? <br /> I] ❑ 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 /> ❑ It Is the system failing? <br /> ❑ Discharge of sewage to the ground surface? <br /> ❑ El Discharge of sewage to drain tiles or surface waters? <br /> ❑ El 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 • 3/28/2026 <br /> anon: <br /> (*This line only can • <br /> '41".... iir 12/31/2025 <br /> Original Siona 0s Date: <br /> Note: Maintenance providers ust ain in accurate rec• •s of their maintenance contracts, customers, <br /> performance data, and timeline- • ene •• g the contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130 - . <br /> DEQ Annual Operation arid Maintenance Report Form Rev.6/2022 <br />