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Z6, . ovv5Zo- (,U441 <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: KURT SHELTON 503-871-2083 <br /> Phone.. <br /> Site Address: 7071 DUNSMERE ST. SE 082W03A002400 <br /> Parcel#. <br /> city: SALEM MARION <br /> County. <br /> Permit#: 555-24-002039-PRMT 4/25/2025 <br /> Startup date if 1st year in use: <br /> System Model#: AX2ORT NA <br /> s <br /> Y System Serial#: <br /> Report Year: 2025 Date of Service Performed: 12/31/2025 <br /> Email Address: SHELKURT@GMAIL.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 /> El ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> x❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ 0 Is the system failing? <br /> ❑ 0 Discharge of sewage to the ground surface? <br /> ❑ ® Discharge of sewage to drain tiles or surface waters? <br /> ❑ it 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): Cory Morgan - A & B Septic Service <br /> certification#: M 587 3/28/2026 <br /> ('This line only can be fit d Q and phot ---� � Expiration: <br /> Original Signature: Date: 12/31/2025 <br /> Note: Maintenance providers ust m i tain accurate ecords of their maintenance contracts, customers, <br /> performance data, and timelines f r re wing the cont as. These records must be available for inspection upon <br /> request by the agency per OAR 34 - 1-0130(24). <br /> DEQ Anntia.ape-titian dna Maintenance keno!' 711111 <br />