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tst-obla1ll¢z)`� <br /> -ere& State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Prope yowner: ALEXANDER SNEGIREV Phone: 503-989-1022 <br /> Site Address: 6747 TESSA LN. Parcel#: 061 E29B002201 <br /> City. SILVERTON County: MARION <br /> Permit#: 555-21-000780 Start up date if 1st year in use: 1/16/2025 <br /> System Model#: AX2ORT System Serial#: 145048 <br /> Report Year: 2025 Date of Service Performed: N/A <br /> Email Address: alexsnegirev@hotmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> •❑ ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> x❑ ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> I] ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ Q Is the system failing? <br /> ❑ Q Discharge of sewage to the ground surface? <br /> ❑ ❑� Discharge of sewage to drain tiles or surface waters? <br /> ❑ II Sewage backup into plumbing fixtures? <br /> If you answered"Yes"on the last four questions,was a repair permit obtained? If not, explain: <br /> ***********UNOCCUPIED************ <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 •: filled •ut an.*1" •pied.) <br /> / <br /> �,, ` '`� - --- 12/31/2025 <br /> Original Signatu - _-.m,� uSdk Date: <br /> Note: Maintenance provi•ers muT maintain acc ate records of their maintenance contracts,customers, <br /> performance data, and ti elinet•r renewing the ••ntracts. These records must be available for inspection upon <br /> request by the agency per • - ' 0-071-0130(24). <br /> DEG Annual Onera'ion and ',Minter a.rz c-on Form Rev 612022 <br />