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ji 000931 - IMQ <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: <br /> BRUCE SCOTT Phone: 503-866-2811 <br /> 782 TANNER WAY Parcel#: <br /> 072W28A07300 <br /> Site Address: <br /> City: SALEM county: Marion <br /> Permit#: <br /> 555-15-002850 Start up date if 1st year in use: 10/30/15 <br /> System Model#: AX2ORT System Serial#: 131363 <br /> Report Year: 2025 Date of Service Performed: 7/3/2025 <br /> Email Address: BRUCE2SCOTT@YAHOO.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> Q ❑ 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 /> ❑ El Is the system failing? <br /> ❑ Q Discharge of sewage to the ground surface? <br /> El ® Discharge of sewage to drain tiles or surface waters? <br /> ❑ El 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 �^ 'Certification Expiration: 3/28/2026 <br /> ('This line only can be Il doantl c 'e <br /> 12/31/2025 <br /> Originals Date: <br /> Note: Maintenance provid rs m maintain accurat records of their maintenance contracts, customers, <br /> performance data, and time s r renewing the tracts. These records must be available for inspection upon <br /> request by the agency per OAR 3 -071-0130(24). <br /> DEC Annual Operation aul lAa inte'ra r ce Re por rn Rev o:2012 <br />