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i7.0O0g29 ftJQ <br /> „erg_ State of Oregon Department of Environmental Quality <br /> SAAnnual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: HARVEY PRIDHOMME Phone: 503-428-2971 <br /> Site Address: 4938 SAWMILL RD Parcel#: 084W13B 02300 <br /> City: SALEM county: Marion <br /> 555-05-08654 NA <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: 4X20N System Serial#: 105475 <br /> Report Year: 2025 Date of Service Performed: 12/30/2025 <br /> Email Address: beardown5154@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> -a - ❑ --Was-maintenance performed as required by septic system rules and the manufacturer? <br /> E ❑ 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 /> ❑ ❑� 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): Brandon Pitts - A & B Septic Service <br /> *Certification#: M 715 *Certification Expiration: 5/20/2028 <br /> (*This line only can be filled out and photocopied.) <br /> Original Signature: l GLnW Date: 1 Z/31/2025 <br /> Note: Maintenance providers must maintain accurate records of their maintenance contracts,customers, <br /> performance data, and timelines for renewing the contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEC Mnua 1pen/ion antl Maintenance H,;n»Fow .ev 6/2022 <br />