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(� - oocO935- (NQ <br /> -/'�- State of Oregon Department of Environmental Duality <br /> SA Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: MIKE REYNOLDS Phone: 541-221-3328 <br /> Site Address: <br /> 752 TANNER LN. parcel#: 072W28A07500 <br /> City. SALEM County: Marion <br /> 555-13-01476 Permit#: Start updatedate if 1st year in use: NA <br /> System Model#: AX2ON RT System Serial it: 125654 <br /> Report Year: 2025 Date of Service Performed: 7/3/2025 <br /> Email Address: reynoldsma@msn.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> IJ II 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 /> l ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ❑� Is the system failing? <br /> ❑ MI Discharge of sewage to the ground surface? <br /> ❑ ❑� 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 it: M 'Certification Expiration: 3/28/2026 <br /> ("This line only can b: filled out and phdtocobiee <br /> Original Signature: <br /> J Date: 12/31/2025 <br /> Note: Maintenance provider ust aintain ac ate records • their maintenance contracts,customers, <br /> performance data, and timelines • enewing the co -- s. Th-se records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEC Anneal^peatian arid lelEntenarec norm Rev 6/2022 <br />