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State of Oregon Department of Environmental Quality 40—Q(//q / U -- /AJ y <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> PropertyOwner: KEVIN MARTEL Phone: 503-851-1396 <br /> Site Address: 6195 BATTLE CREEK RD. SE Parcel#: 083W24B01300 <br /> City: SALEM county: Marion <br /> Permit#: 555-20-005064 Start up date if 1st year in use: 6/15/21 <br /> System Model#: AX2ORT System Serial#: 145019 <br /> Report Year: 2025 Date of Service Performed: 9/2/2025 <br /> Email Address: MARTELSN@COMCAST.NET <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> tEl ❑ 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 /> _❑ El Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ It Is the system failing? <br /> El 0 Discharge of sewage to the ground surface? <br /> ❑ El Discharge of sewage to drain tiles or surface waters? <br /> ❑ IN 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 /> M 587 3/28/2026 <br /> Expirati <br /> 'Certification #,� - - nation on: <br /> -( t his line only can •= Ile• out and p = • •ed. <br /> Original Signature: AA � � Date: 12/31/2025 <br /> Note: Maintenance provider mu• main).'n accurate recor, of their maintenance contracts,customers, <br /> performance data, and timelin- f•r renewin• •- contracts. ' hese records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEC Annual Operation ann Maintenance 4er ert roan Rev 62E22 <br />