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State of Oregon Department of Environmental Quality a73 v✓ / &0 7 /A4/ <br /> SAAnnual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> CASEY LUNDEEN AND LAUREN ATKIN 503-930-1618 <br /> Property Owner: Phone: <br /> 8849 ENCLID ST. NE 072W13CA01100 <br /> Site Address: Parcel#: <br /> city: SALEM Marion <br /> County: <br /> Permit#: 555-21-005895-PRMT 12/14/24 <br /> Startup date N 1st year in use: <br /> AX2ORT LOGO System Model#: <br /> System Serial#: <br /> Report Year: 2025 5/30/2025 <br /> P Date of Service Performed: <br /> Email Address: CLUNDEEN318@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> I] LI Was maintenance performed as required by septic system rules and the manufacturer? <br /> I] 0 Is the system operating in accordance with the agent-approved design specifications? <br /> I] ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> O Q Is the system failing? <br /> ❑ ® Discharge of sewage to the ground surface? <br /> ❑ 0 Discharge of sewage to drain tiles or surface waters? <br /> LI II 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 canled <br /> be put and pho — <br /> Original Signature: _A -IA�. Date: 12/31/2025 <br /> Note: Maintenance provider- ust ; aintain accurate r:cords of their maintenance contracts,customers, <br /> performance data, and timelines o enewing the contra cis. These records must be available for inspection upon <br /> request by the agency per OAR 340-0 i • . . <br /> DEC)Annual Operation and Maintenance Report Faun <br /> Rev.6/2022 <br />