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State of Oregon Department of Environmental Quality kr V)/ // J//// <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: JODY MANDISH Phone: 503-936-6369 <br /> Site Address: 14861 CANYON VIEW LN. Parcel#: 071W120000605 <br /> city: SILVERTON county: Marion <br /> 03-01007 Start up date if 1st year in use: 5/19/17 <br /> Permit#: <br /> System Model#: AX2ORT System Serial#: 134261 <br /> Report Year: 2025 Date of Service Performed: 8/22/2025 <br /> Email Address: Ysipuew@yahoo.com <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 /> _❑ ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> ❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ IIIII] Is the system failing? <br /> ❑ Q 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 certifythatthis-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.) <br /> Original Signature: hlan ( 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 /> DE]Ann ai Operation and maintenance Report l arm Rev 6:2022 <br />