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20- c ��s irtQy <br /> 1 tv 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: VICTOR AKOTNEKOFF phone: 702-327-0950 <br /> 10391 KISKA DR. 093W10A000506 <br /> Site Address: Parcel#: <br /> city: JEFFERSON County: Marion <br /> 09-04457 <br /> Permit#: Start up date if 1st year in use: NA <br /> System Model#: AX2ORT System Serial#: 135892 <br /> Re port Year: 2025 3/18/2025 <br /> P Date of Service Performed: <br /> Email Address: AKAVIC25@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> ❑ 0 Was maintenance performed as required by septic system rules and the manufacturer? <br /> O ❑ 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 /> ❑ Q Is the system failing? <br /> ❑ ❑� Discharge of sewage to the ground surface? <br /> ❑ ® Discharge of sewage to drain tiles or surface waters? <br /> ❑ a 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#: M 587 *Certification Expiration: 3/28/2026 <br /> (*This line only cahbe out and p to pied.) <br /> Original Signature: Date: 12/31/2025 <br /> Note: Maintenance providers ust mai tain ccurate records of their maintenance contracts,customers, <br /> performance data, and timelines for ren ixk�the contracts, These records must be available for inspection upon <br /> request by the agency per OAR 340-071- 0(24). <br /> DEO Annual Operation and tAa'"tensi e Report Cr= v <br /> Rev.6121)22 <br />