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22-05D I SiSID 00 `I <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: Silvia Silva Rodriguez Phone: 503-990-4306 <br /> Site Address: 6257 LAHAINA LN. NE Parcel#: 072W21 D01402 <br /> City' SALEM County: Marion <br /> Permit#: 555-20-005656- PRMT Start up date if 1 st year in use: 11/19/20 <br /> AX2ORT 144116 <br /> System Model#: System Serial#: <br /> Report Year: 2025 Date of Service Performed: 6/9/2025 <br /> Email Address: SILVASILVIA128@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> x❑ ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> Q 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 /> El U Is the system failing? <br /> D 1.1 Discharge of sewage to the ground surface? <br /> ❑ It Discharge of sewage to drain tiles or surface waters? <br /> ❑ ® 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 87 "Certification Expiration: 3/28/2026 <br /> ('This line only can - filled o =nd : • ied. <br /> 1 . 12/31/2025 <br /> Original Signatur> ,v _ �S - --- Date: <br /> Note: Maintenance provider mu aintain accurate ecords of their maintenance contracts, customers, <br /> performance data,and timelin- ,r renewing the con -cts. These records must be available for inspection upon <br /> request by the agency per OAR 0-071-0130(24). <br /> DEO Annual Operation and Maintenen ee Report Rev.6'2022 <br />