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Ii, ;916 (A) Q <br /> -.-7- 2 State of Oregon Department of Environmental Quality <br /> SAAnnual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> PropertyOwner: Lal Sidhu Phone: 503-910-6527 <br /> Site Address: 7501 35th Ave NE Parcel#: 063W24D001500 <br /> City. Salem County: Marion <br /> Permit#: 08-02098 Start up date if 1st year in use: NA <br /> System Model#: AX2O-1 B System Serial#: 115370 <br /> Report Year: 2025 Date of Service Performed: 4/8/2025 <br /> Email Address: lalsidhu@comcast.net <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> .❑ El 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 /> x❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ❑� Is the system failing? <br /> O ❑ Discharge of sewage to the ground surface? <br /> ❑ MI Discharge of sewage to drain tiles or surface waters? <br /> El HI Sewage backup into plumbing fixtures? <br /> If you answered"Yes"on the last four questions,was a repair permit obtained? If not,explain: <br /> SIGNS OF DRAINFIELD FAILURE <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 it: M 587 'Certification Expiration: 10/31/26 <br /> ('This line only can b. fill-• •ut an• . • o i•ied.) <br /> Original Signature __ _� -- Date: <br /> 12/31/2025 <br /> Note: Maintenance providers `t maintain accurate ecords of their maintenance contracts, customers, <br /> performance data, and ti eli - .r renewing the cont 'cts. These records must be available for inspection upon <br /> request by the agency per a 40-071-0130(24). <br /> DEC)Annual Operation and Maintenance or.Rorin Rev G2022 <br />