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217(-- 0o1/ — /4\/ <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ <br /> Report Form <br /> General Information (Complete ALL information) <br /> Property owner: CHRIS & MELISSA BRAVO Phone: 503-586-3172 <br /> Site Address: 6015 BARCELONA DR SE Parcel#: 082W20A00400 <br /> City: SALEM county: Marion <br /> Permit#: 555-22-007282-PRMT Start up date if 1st year in use: 10/05/2023 <br /> System Model it: System Serial#: LOGO BOARD <br /> Report Year: 2025 Date of Service Performed: 11/19/2025 <br /> Email Address: melissa.bravo@comcast.net <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> _L'J U -Vitas maintenance performed as required by septic system rules and the manufacturer? <br /> a ❑ 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 /> ❑ a 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 fill2 o and photoco•`> ) <br /> 3 /! Date: 12/31/2025 <br /> Original Signature: _ - <br /> Note: Maintenance providers mu- •i,'• .in ace - - cords of their maintenance contracts, customers, <br /> performance data, and timelines for renewing the con - s. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEC)Annual Operation and Maintenance Report Form Rev.6/2022 <br />