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a a - \(aqtr' <br /> f _ 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: JAMES MITCHELL Phone: 541-600-2154 <br /> Site Address: 6567 LIPSCOMB ST. SE. Parcel#: 082W15C 00800 <br /> city: SALEM County: Marion <br /> Permit#: 555-20-003799-PRMT Start up date if 1st year in use: 1/21/21 <br /> AX2ORT System Serial#: 141705 <br /> System Model#: <br /> Report Year: 2025 Date of Service Performed: 10/27/2025 <br /> Email Address: mitchell.jim.p@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> El El Was maintenance performed as required by septic system rules and the manufacturer? <br /> ❑ ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> Q ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ I• Is the system failing? <br /> ❑ ❑� Discharge of sewage to the ground surface? <br /> ❑ El Discharge of sewage to drain tiles or surface waters? <br /> ❑ It 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 *Certification Expiration: 3/28/26 <br /> ('This line only can be fil d out and p afdco i ) <br /> Original Signature: (( Date: <br /> 12/31/2025 <br /> Note: Maintenance provide must rSta. accurate r ords of their maintenance contracts,customers, <br /> performance data,and timelines or renewing the acts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEO Annual Operation and Maintenance Report Farm. Rev.612022 <br />