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25 0O514.0D4NQJ <br /> ,ram State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> rife <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> PropertyOwner: ANTOINETTE BOX Phone: 503-580-0995 <br /> 9895 72ND AVE NE 062W10D00400 <br /> Site Address: Parcel#. <br /> City: SALEM County: Marion <br /> 08-02946 09/26/2024 <br /> Permit#. Start up date if 1st year in use: <br /> System Model#: AX2ORT System Serial#: MVP <br /> Report Year: 2025 Date of Service Performed: 10/16/2025 <br /> Email Address: TONIBOXI@COMCAST.NET <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> Q ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> I] ❑ 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 /> ❑ I] Is the system failing? <br /> El • Discharge of sewage to the ground surface? <br /> ❑ IN Discharge of sewage to drain tiles or surface waters? <br /> ❑ It Sewage backup into plumbing fixtures? <br /> If you answered"Yes"on the last four questions,was a repair permit obtained? If not, explain: <br /> 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 ed oui and o i ) <br /> Original Signature: Date: 12/31/2025 <br /> Note: Maintenance providers t aintain accurate cords of their maintenance contracts,customers, <br /> performance data, and timelines for re the con cts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130( <br /> DEC)Annual Operation and Maintenance Report Form <br /> Rev &2022 <br />