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fl tw&b3:31: <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: SHANNON CAMPBELL Phone: 503-949-4379 <br /> Site Address: 3238 LITTLE HAVEN LANE S. Parcel#. 083W07A 02301 <br /> City: SALEM County: Marion <br /> Permit#: Start Start up date if 1st year in use: 11/9/2007 <br /> System Model#: AX2ON System Serial#: 113110 <br /> Report Year: 2025 Date of Service Performed: 12/12/2025 <br /> Email Address: CAMPBELLDESIGNS@MAC.COM <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 /> 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 I] Is the system failing? <br /> ❑ 0 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#: M 587 *Certification Expiration: 3/28/2026 <br /> ('This line only can be ratitit and photocopi==.) <br /> Original Signature:\% ib_r— A is. Date: 12/31/2025 <br /> Note: Maintenance providers t m4 tam accurate records of their -intenance contracts, customers, <br /> performance data, and timelines for rene • _ • tracts. These re ,.rds must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> oLO Amraal Opera!on antl Maimena-ice Repon 00013 Rev.1312022 <br />