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��- DDD/60q IN <br /> State of Oregon Department of Environmental Quality <br /> SAAnnual Operation and Maintenance <br /> DEQ <br /> Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: KERRI TRAPP Phone: 503-559-1543 <br /> Site Address: 8485 Amanda Way SE parcel#: 082W02AA00102 <br /> city: Salem County: Marion <br /> Permit#: 04-07322 Start up date if 1st year in use: 8/9/2005 <br /> System Model#: AX20 1 B System Serial#: 105793 <br /> Report Year: 2025 Date of Service Performed: 12/30/2025 <br /> Email Address: katozzie@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> a 0 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 /> Q ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ❑� Is the system failing? <br /> ❑ i] Discharge of sewage to the ground surface? <br /> ❑ i] Discharge of sewage to drain tiles or surface waters? <br /> ❑ Ill 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): 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 /> ...)3 <br /> Original Signature: / 7T1- Date: <br /> 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 /> DEP Annual°per31io1,and Maintenance Repo'I oun Rev 6/2022 <br />