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17- 8009.59- IA16 <br /> -e-rq, State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: LON STANCZYK Phone: 503-999-3131 <br /> Site Address: 5080 GAFFIN RD, parcel#: 082W05A 02100 <br /> City: SALEM County: Marion <br /> Permit#: 555-11-01952 Start up date if 1st year in use: 10/3/2011 <br /> System Model#: AX2ORT System Serial#: LOGO <br /> Report Year: 2025 Date of Service Performed: 12/31/2025 <br /> Email Address: ionnieStanczykQ@grnall.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> x❑ ❑ 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 /> x❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ IN Is the system failing? <br /> ❑ 0 Discharge of sewage to the ground surface? <br /> ❑ MI 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 /> M 587 3/28/2026 <br /> 'Certification#: 'Certification Expiration: <br /> (*This line only can fille'y out and otocopied.) <br /> original Signature. 1` / Date: 12/31/2025 <br /> Note: Maintenance providers u st intai accurate records of their maintenance contracts,customers, <br /> performance data, and timelin r renewi the contracts. These records must be available for inspection upon <br /> request by the agency per OAR 0-071-01 0(24). <br /> DEG AnnraI Jneaton are)Maintenance Report Form Rev 612022 <br />