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State of Oregon Department of Environmental QualityW I� "� � <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Propertyowner: RYAN LEWIS Phone: 503-932-6926 <br /> Site Address: 1694tOVICH LN. SE Parcel Jr 082W30DB00301 <br /> City: <br /> SALEM 1LCL9 county: Marion <br /> UNKNOWN Start up date if 1st year in use: 3/10/21 <br /> Permit#: <br /> System Model#: AX2ON System Serial#: 143147 <br /> Report Year: <br /> 2025 Date of Service Performed: 4/25/2025 <br /> Email Address: RYANLEWISJ@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> a ❑ 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 /> ❑ Discharge of sewage to the ground surface? <br /> ❑ I9 Discharge of sewage to drain tiles or surface waters? <br /> ❑ Q Sewage backup into plumbing fixtures? <br /> If you answered"Yes"on the last four questions,was a repair permit obtained? If not, explain: <br /> t 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 f out and p tocopied.) <br /> 12/31/2025 <br /> Original Signature: j__.__—. -- Date: <br /> -- Note: Maintenance providers aintain accurat records of their maintenance contracts,customers, <br /> performance data,and timelines or renewing the con cts. These records must be available for inspection upon <br /> request by the agency per OAR -071-0130(24). <br /> OEM Annual Operation and Maintenance Report Form Rev 612022 <br />