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Z2- 60I ')310 -I N6' <br /> State of Oregon Department of Environmental Quality <br /> Sik Annual Operation and Maintenance <br /> Ira <br /> DEQ <br /> Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: RAY TEMPLE phone: 503-413-0652 <br /> Site Address: 8353 WAGNER CT. SE parcel#: 082W11D 01000 <br /> City: SALEM county: Marion <br /> Permit#: 555-20-001905-PRMT Start up date if 1st year in use: 8/11/20 <br /> System Model#: X20RT System Serial#: 143521 <br /> Report Year: 2025 Date of Service Performed: 10/15/2025 <br /> Email Address: RLT2648@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> E ❑ 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 /> x❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ❑� Is the system failing? <br /> ❑ MI Discharge of sewage to the ground surface? <br /> ❑ Q Discharge of sewage to drain tiles or surface waters? <br /> ❑ MI 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 tfiaithis 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#: IS;7 *Certification Expiration: 3/28/26 <br /> ('This line only ca •=fille• out and��i -• <br /> ,��y/ 12/31/2025 <br /> Original Signatu -: a A A Date: <br /> Note:Maintenance providers mus maintain .ccurate records of their -intenance contracts,customers, <br /> performance data,and imeli es fo renew' a the contracts. These rec rds must be available for inspection upon <br /> request by the agency p.r 0 R 341 071-0140(24). <br /> DEG el a'cr. ��aie�_e FNp- ., - c-« <br />