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State of Oregon Department of Environmental Quality 023, CID I / M?" <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: ANTONIO TREJO Phone: 503-580-1745 <br /> Site Address: 1632 WHISPERING WAY SE Parcel#: 082W04A002701 <br /> City: SALEM County: Marion <br /> Permit#: 11-06975 Start up date if 1st year in use: 10/31/22 <br /> AX25RT 147465 <br /> System Model#: System Serial#: <br /> Report Year: 2025 Date of Service Performed: 9/8/2025 <br /> Email Address: antontre@aol.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> I] ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> x❑ ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> x❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ It Is the system failing? <br /> ❑ II Discharge of sewage to the ground surface? <br /> ❑ I] Discharge of sewage to drain tiles or surface waters? <br /> ❑ It Sewage backup into plumbing fixtures? <br /> If you answered"Yes"on the last four questions,was a repair permit obtained? If not,explain: <br /> 1 certify-that thisreport 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 /> • <br /> Original Signature: 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 /> DEO Anntia Operatic aafi ferlanceR ,ii.. um Rm i 202[ <br />