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State of Oregon Department of Environmental Quality 02 — On 75 /NQ/ <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL Information) <br /> Property owner: LANDON & NATHAN ANSON Phone: 971-205-8813 <br /> 1672 WHISPERING WAY SE Parcel JP <br /> 082W04A002703 <br /> Site Address: <br /> City: SALEM County: Marion <br /> 11-06976 Start up date it 1st year in use: 7/28/22 <br /> Permit#: <br /> System Model#: AX2ORT System Serial#: LOGO <br /> Report Year: 2025 Date of Service Performed: 5/23/2025 <br /> Email Address: NATHANWSMETZLER85@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> Q ❑ 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 /> ❑ 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 /> 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 can be fill ut and photocopied.) <br /> 12/31/2025 <br /> Original Signature: --> Date: <br /> Note: Maintenance providers u#t maintain a ate 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 /> DEC Annual Operation am ntenaece Repor:cam Rev 62U?t <br />