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State of Oregon Department of Environmental Quality /7 (/UV 752 A <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: JOSE MACIAS phone: 503-990-1526 <br /> Site Address: 5615 MACLEAY RD. SE Parcel#: 072W33C 00500 <br /> city: SALEM County: Marion <br /> Permit#: 555-15-004779-SEP Start up date if 1st year in use: 06/15/16 <br /> AX2ORT 132272 <br /> System Model#: System Serial#: <br /> Report Year: 2025 Date of Service Performed: 10/16/2025 <br /> Email Address: JOSE-D-MACIAS12@HOTMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> n ❑ 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 /> ❑ El Is the system failing? <br /> ❑ 0 Discharge of sewage to the ground surface? <br /> ❑ • Discharge of sewage to drain tiles or surface waters? <br /> ❑ MI 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 • t and phot ed.) <br /> Original Signature: /l- Date: 12/31/2025 <br /> Note: Maintenance providers mu•t :intain -ccurate rec• ds of their maintenance contracts,customers, <br /> performance data, and timelines fo newing - contra . These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DE()Arnua:Operation MainterianLe Reoor I orm Hey 61[11.2[ <br />