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State of Oregon Department of Environmental Quality �c? " 4/7> _ /4/ <br /> Annual Operation and Maintenance <br /> $EQ, Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: STEPHANIE MALHERBE Phone.. 503-559-3435 <br /> Site Address: 2802 STRONG RD. SE Parcel#. 083W12B002000 <br /> City: SALEM Marion <br /> County: <br /> Permit#: 19-005242 8/17/2020 <br /> Start up date if 1st year in use: <br /> AX2ON 141591 System Model#. <br /> System Serial#: <br /> Report Year: 2025 Date of Service Performed: 12/31/2025 <br /> Email Address: SMREEH@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> 0 ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> 0 0 Is the system operating in accordance with the agent-approved design specifications? <br /> 0 ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ 0 Is the system failing? <br /> ❑ NE Discharge of sewage to the ground surface? <br /> ❑ ® 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 car B Septic Service <br /> 'Certification it <br /> cation 587 'Certification Expiration: 3/28/2026 <br /> (*This line only can be filled out and photocopied)Original Signature: J � Date: 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 /> DEOAna Operation and M -t.na ace rc _i - <br />