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1-/ -0-oo95t - /NQ <br /> ..r 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: WELDON RYAN Phone: 503-569-5821 <br /> Site Address: 5215 S. RIVER RD. parcel#: 084W14A 02400 <br /> SALEM -- County: Marion <br /> Permit#: 555-09-04777 Start up date if 1st year in use: NA <br /> AX2ON 128356 <br /> System Model#: System Serial#: <br /> Report Year: 2025 Date of Service Performed: 10/27/2025 <br /> Email Address: wrf eep O@yall0O.c0m <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 /> x❑ ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> El ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ❑� Is the system failing? <br /> ❑ 0 Discharge of sewage to the ground surface? <br /> ❑ Q 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 *Certification Expiration: 3/28/2026 <br /> ('This line only can berNedou ao ) <br /> Original Signature. \ Date: 12/31/2025 <br /> Note: Maintenance provid rs mu maintain curate cords f their maintenance contracts, customers, <br /> performance data, and time S es r renewing t contracts. T ese records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEG Annual Operation and Maintenance Report=orin Rev 6'2022 <br />