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State of Oregon Department of Environmental Quality <br /> 17- 06023i - I1\lk <br /> Annual Operation and Maintenance <br /> DEQ., Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: ROY & JENNIFER BENNETT Phone: 541-391-7788 <br /> Site Address: 10656 OAK DR. SE Parcel#: 093W10C 00800 <br /> City: SALEM County: Marion <br /> Permit it: 10-03661 Start up date if 1st year in use: NA <br /> System Model#: AX20-1 A System Serial#: 114812 <br /> Report Year: 2025 Date of Service Performed: 12/31/2025 <br /> Email Address: EWEOLOGY@AOL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> 0 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 /> x❑ ❑ 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): CORY MORGAN - A & B Septic Service <br /> *Certification#: M 587 'Certification Expiration: 03/28/2026 <br /> (*This line only can be filled out and photocopied.) <br /> Original Signature: <br /> Date: 12/31/2025 <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 /> DEOHnal iDpeallon and MaTtenan'x f > rt Fero Hey b'2022 <br />