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/'q, State of Oregon Department of Environmental Quality ' ©UD 5,,? _y 1Q <br /> Annual Operation and Maintenance <br /> Pa <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: JIM MIKESH Phone: 503-931-8381 <br /> 2531 QUINABY MEADOWS NE 063W24AC00601 <br /> Site Address: Parcel#: <br /> City: SALEM county: Marion <br /> Permit#: 08-05527 Start up date if 1st year in use: 7/1/09 <br /> System Model#: AXZON System Serial#: 115724 <br /> Report Year: 2025 Date of Service Performed: 7/7/2025 <br /> Email Address: .1immikesh@q.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> -u -❑ -Was maintenance performed as required by septic system rules and the manufacturer? <br /> x❑ 0 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 /> ❑ UI Discharge of sewage to the ground surface? <br /> ❑ ❑� 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 /> -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 /> Ce tfication# --- Certification Expiration: 3/28/2026 <br />. -----— ('This line only n be fills 'out and :gp O ' d.) -- <br /> Original Signa • I\/ Date: 12/31/2025 <br /> Note: Maintenance prov rs t maintain accurate cords of their maintenance contracts, customers, <br /> performance data,and time s for renewing the contr ts. These records must be available for inspection upon <br /> request by the agency per OA 340-071-0130(24). <br /> DEG Annual Operation and Maintenance Report Form Rev.62022 <br />