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6a/ O7 —/'d j <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: RICK & SALLY LEWIS Phone: 503-583-2066 <br /> 7644 DOVICH LN SE Parcel#: 082W30DB00302 <br /> Site Address: <br /> city: SALEM County: Marion <br /> Permit#: 555-21-006544-PRMT Start up date if 1st year in use: 5/23/22 <br /> System Model#: AX2ORT System Serial#: 146598 <br /> Report Year: 2025 Date of Service Performed: 10/27/2025 <br /> Email Address: Iouie4ever@comcast.net <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> ❑x ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> Q ❑ 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 /> ❑ Q Is the system failing? <br /> ❑ Q Discharge of sewage to the ground surface? <br /> ❑ ❑� Discharge of sewage to drain tiles or surface waters? <br /> ❑ III 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: 3/28/2026 <br /> (*This line only can be fill t and photoco 'ed.) <br /> Original sign-dive: -) Date: 12/31/2025 <br /> Note: Maintenance providers must mar tar ccurat records of their maintenance contracts, customers, <br /> performance data,and timelines for renewing t These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEP Annual Operation and Maintenance Report Farm Rev.62022 <br />