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State of Oregon Department of Environmental Quality �39 1 v iDo Z 1/14('j <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner ROD LENT Phone: 503-949-9125 <br /> Site Address: 4530 CORDON RD. NE Parcel# 072W05D 00400 <br /> city: SALEM County: Marion <br /> Permit#: 555-22-003184 Start up date if 1st year in use: 7/7/22 <br /> System Model#: MICROFAST System Serial#: N/A <br /> Report Year: 2025 Date of service Performed: 7/31/2025 <br /> Email Address: RODLENT1957@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> D LI Was 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 /> O E Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ • Is the system failing? <br /> ❑ IN Discharge of sewage to the ground surface? <br /> ❑ I 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): Brandon Pitts - A & B Septic Service <br /> *Certification#: M 715 *Certification Expiration: 5/20/2028 <br /> ('This line only can be filled out and photocopied.) J <br /> Original Signature: Date: <br /> 12/31/2025 <br /> Note: Maintenance providers must maintain accurate records of their maintenance contracts, customers, <br /> performance data,and timelines for renewing the contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> BEG 1 Ope.ation anc Maintenance R art FJIm Nov L:2022 <br />