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- bitA33-71/Q <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: BRENT & AIMEE MENDONCA Phone: 971-600-8231 <br /> Site Address: <br /> 3249 64TH PL. NE Parcel#: 072W09D02200 <br /> City: SALEM coons: Marion <br /> Permit#: 555-15-002089 Start up date if 1st year in use: NA <br /> System Model#. <br /> AX20-1 B System se al#. 131259 <br /> Report Year: <br /> 2025 Date of Service Performed: 11/4/25 <br /> Email Address: UNKNOWN <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> 9 ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> li ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> _❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ I] Is the system failing? <br /> ❑ 9 Discharge of sewage to the ground surface? <br /> ❑ It Discharge of sewage to drain tiles or surface waters? <br /> ❑ I Sewage backup into plumbing fixtures? <br /> If you answered"Yes"on the last four questions,was a repair permit obtained? If not, explain: <br /> 1 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 andfor civil penalties. <br /> 'Maintenance Provider Name(please print): Cory Morgan - A & B Septic Service <br /> "Certification#: 'Certification 587 'Certification Expiration: 3/28/2026 <br /> ('This line only can be t and p •i•co•1=d.1 <br /> Or'�'• - ure: <br /> er ' 11, -- Date: 12/31/2025 <br /> Note: Maintenance provider must aintain - urate recor•- of their maintenance contracts, customers, <br /> performance data,and timeline • -newing the cc - . These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEG Annual Operation and Maintenance Report Form Rev 82E22 <br />