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ob0722 <br /> . 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: SAM ANFILOFIEFF Phone: 503-504-2314 <br /> 14530 NIKITA LN. NE 061W25C01001 <br /> Site Address: Parcel#: <br /> City: SILVERTON county: Marion <br /> 555-13-005279-SEP <br /> Permit#: Start up date if 1st year in use: NA <br /> System Model#: AX2ORT System Serial#: 128228 <br /> Report Year: 2()25 Date of Service Performed: 8/22/2025 <br /> Email Address: spremiumplus@hotmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> r <br /> x- LJ 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 /> ID El Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ 0 Is the system failing? <br /> ❑ IN Discharge of sewage to the ground surface? <br /> ❑ 0 Discharge of sewage to drain tiles or surface waters? <br /> ❑ ® 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-thai 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): Brandon Pitts - A & B Septic Service <br /> *Certification#: M 715 *certification Expiration: 5/20/2028 <br /> ('This line onty can be filled out and photocopied.) <br /> Original Signature: 13A ndn Date: 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 /> DFC Annual operation and Vam',e nance Report Form Rev.o.2022 <br />