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State of Oregon Department of Environmental Quality <br /> 11 -ootm°t53 -7\1• 1 <br /> Annual Operation and Maintenance <br /> via <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: WILLIAM SMITH Phone: 626-254-1293 <br /> Site Address: 4758 FOX LN. S Parcel#: 084W36CC00100 <br /> City. SALEM County: Marion <br /> Permit#: 10-02086 Start up date if 1st year in use: NA <br /> System Model#: AX2ORT System Serial#: 121489 <br /> Report Year: 2025 Date of Service Performed: 4/4/2025 <br /> Email Address: SMITHLAW06@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> E ❑ 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 /> ❑ 0 Is the system failing? <br /> ❑ El Discharge of sewage to the ground surface? <br /> ❑ Q Discharge of sewage to drain tiles or surface waters? <br /> ❑ 0 Sewage backup into plumbing fixtures? <br /> If you answered"Yes"on the last four questions,was a repair permit obtained? If not, explain: <br /> 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: 3/28/26 <br /> ('This line only can be fill ut and oto pied) <br /> Original Signature: P7t -- <br /> Date: 12/31/2025 <br /> Note: Maintenance providers mu maintain acc ate records of their maintenance contracts, customers, <br /> performance data, and timelin r newing the ontracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071- 0(2 . <br /> DE()Animal Operation and Maintenance Report I ann Rev 6:2022 <br />