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State of Oregon Department of Environmental Quality / 7 a - Z/ / "l <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: JULIE KELLY Phone: 503-385-5711 <br /> Site Address: 1509 RIVERHAVEN DR. S Parcel#: 073W30CC01100 <br /> ci y: SALEM County Marion <br /> 07-05852 Start up date if 1st Y ear in use: 09/18/2007 <br /> Permit#: <br /> System Model#: AX20-1 B System Serial#: 110024 <br /> Report Year: 2025 Date of Service Performed: 10/10/2025 <br /> Email Address: CASEYMW40@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefilt and photocopy checkboxes) <br /> Yes No <br /> ❑ ❑ 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 /> n ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ 0 Is the system failing? <br /> ❑ E. Discharge of sewage to the ground surface? <br /> ❑ 1.1 Discharge of sewage to drain tiles or surface waters? <br /> ❑ Q 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 can be)N and pho • ••ied. <br /> ure: Imp►- f Date: 12/31/2025 <br /> Note: Maintenance provide - r ust aintain accurat- records of their maintenance contracts, customers, <br /> performance data, and timelin- • -ne •• - ontracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEC Annua Operation and Maintenance Report t arm Rev.02022 <br />