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State of Oregon Department of Environmental Quality 242- `-'�-'�3 \ <br /> Annual Operation and MaintenanceriS <br /> UX <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: DAN IZOITA Phone: 564-888-3572 <br /> 6627 MARY LN. Parcel#: 061 E29A 01603 <br /> Site Address: <br /> city: SILVERTON county: MARION <br /> Permit#: <br /> 555-24-002532-PRMT Start up date if 1st year in use: 01/16/25 <br /> System Model#: AX2ORT System Serial#: LOGO <br /> Report Year: 2025 Date of Service Performed: 10/28/2025 <br /> Email Address: DAN@CROWLEYSGRANITE.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> U LI -Was maintenance performed as required by septic system rules and the manufacturer? <br /> ▪ ❑ 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 /> ❑ In Is the system failing? <br /> ❑ ® Discharge of sewage to the ground surface? <br /> ❑ II Discharge of sewage to drain tiles or surface waters? <br /> El • 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): Brandon Pitts - A & B Septic Service <br /> *Certification#: M 715 'Certification Expiration: 5/20/2028 <br /> (*This line only can be filled out and photocopied.) <br /> Original Signature: <br /> /� 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 /> DI Q Annuai Operation ana Idairnenanee Report Form Rev 6:2022 <br />