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,2 2 3/93-/3 y <br /> _erg, State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> gra <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: SAZ YAKIS Phone: 503-951-3228 <br /> 7294 ELMERS CT. NE 061E20004400 <br /> Site Address: Parcel#: <br /> City. SILVERTON county: Marion <br /> 555-20-003387 <br /> Permit#: Start up date if 1st year in use: NA <br /> System Model#: AX2ORT System Serial#: 142102 <br /> Report Year: 2025 Date of Service Performed: 9/30/2025 <br /> Email Address: IRONMANSAZ@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> I] 0 Was maintenance performed as required by septic system rules and the manufacturer? <br /> I] ❑ 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 /> ❑ IN Is the system failing? <br /> ❑ I] Discharge of sewage to the ground surface? <br /> ❑ • Discharge of sewage to drain tiles or surface waters? <br /> ❑ 0 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 it: M 587 *Certification Expiration: 3/28/2026 <br /> ('This line only can •- filled out amp .i t d.) <br /> r• S <br /> Original SignatuHAM . Date: 12/31/2025 <br /> Note: Maintenance provi peps mus maintain ac • ate re••rds of their maintenance contracts,customers, <br /> performance data,and ti 'dines f• renewinp, the contra s. These records must be available for inspection upon <br /> request by the agency per . R 3- r-071-0140(24). <br /> DLO Annual:ape-at,on Nla utenanaa repo¢-cnn u U022 <br />