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_erg., State of Oregon Department of Environmental Quality tl-t7OO `LS)'IA <br /> ! Annual Operation and Maintenance <br /> Wilil <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: SERGIO CANCHOLA Phone: 503-269-8527 <br /> Site Address: 7163 CONIFER ST NE Parcel#: O72W22DOOO5OO <br /> city: SALEM county: Marion <br /> 12-0230 NA <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: AX20N System Serial#: 125842 <br /> Report Year: 2025 Date of Service Performed: 11/20/2025 <br /> Email Address: canch0lasergi0@ymali.00M <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 /> El 0 Is the system operating in accordance with the agent-approved design specifications? <br /> x❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ II Is the system failing? <br /> ❑ in Discharge of sewage to the ground surface? <br /> ❑ Q Discharge of sewage to drain tiles or surface waters? <br /> ❑ ii 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 fit-• •• and photoco•'-•.) <br /> et A <br /> Original Signature: Ai. <br /> . 4t�wev� Date: 1Z/31/Z0Z5 <br /> Note:Maintenance providers ain.-in accurate r:cords of their maintenance contracts, customers, <br /> It <br /> performance data,and timelines or rene •• the contra s. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130 4). <br /> DR)Annual Operation and Maintenance Report Four Rev 62022 <br />