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State of Oregon Department of Environmental Quality a�-et)I1W <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: GREG CALKINS Phone: 503-383-8656 <br /> Site Address: 2195 62ND AVE. SE parcel#: 082W04A 03800 <br /> City. SALEM County: Marion <br /> Permit#: 5555-23-002107-PRMT Start up date if 1st year in use: 5/18/23 <br /> AX2ORT 147793 <br /> System Model#: System Serial#: <br /> Report Year: 2025 Date of Service Performed: 10/16/2025 <br /> Email Address: GCALKINS@WIREWORKS,CO <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> Q U Was maintenance performed as required by septic system rules and the manufacturer? <br /> li ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> z❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ © Is the system failing? <br /> ❑ Ui Discharge of sewage to the ground surface? <br /> El IUi Discharge of sewage to drain tiles or surface waters? <br /> ❑ MI 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: 3/28/26 <br /> ('This line only can be fille (and photocopied) <br /> Original Signature: Date: <br /> 12/31/2025 <br /> Note: Maintenance providers mus in t i accurate ecords of their maintenance contracts,customers, <br /> performance data,and timelines for renewing w tracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEE Annual:Ece:atlon am Ma ve.nance Repoet Farm Rev.R2022 <br />