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,/`g. State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> PropertyOwner: CHRISTOPHER CARR Phone: 503-881-1598 <br /> s eAddress: 8582 ASHDOWN CT. SE Parcel 072W36B001401 <br /> City: SALEM County: Marion <br /> Permit#: 07-03220 Start up date if 1st year in use: 6/5/08 <br /> System Model#: AX20-1 A System Serial#: 112796 <br /> Report Year: 2025 Date of Service Performed: 6/16/2025 <br /> Email Address: CHRIS@CHRISCARR.ME <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 /> x❑ ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> I] ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ Q Is the system failing? <br /> ❑ It Discharge of sewage to the ground surface? <br /> ❑ IIIIII Discharge of sewage to drain tiles or surface waters? <br /> ❑ co 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 filhrdaut and photocopied.) <br /> l 4 , 12/31/2025 <br /> Original Signature: '�� Date: <br /> Note: Maintenance provider it st aintain accur to records of their maintenance contracts, customers, <br /> performance data, and timelines o -- .'n• •• .ontracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DSO Annual Operation and Mantcrtanra Rcooc Horn Rev ti2022 <br />