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State of Oregon Department of Environmental Quality CO 21 33 St3(LR <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> l ,a5ta5 <br /> General Information (Complete ALL information) <br /> Property Owner: STANISLAV & VERA GIDENKO Phone: 503-930-6072 <br /> Site Address: 2375 CLOVERDALE DR. SE Parcel#: 093W02A001300 <br /> City: TURNER County: MARION <br /> Permit#: 01-04792 Start up date if 1st year in use: 7/11/25 <br /> System Model#: AX2ORT System Serial#: LOGO <br /> Report Year: 2025 _ Date of Service Performed: <br /> Email Address: VGIDENKO@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> I] ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> Q ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> Q El 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 /> ❑ MI Sewage backup into plumbing fixtures? <br /> If you answered"Yes"on the last four questions,was a repair permit obtained? If not, explain: <br /> "' START UP DONE AFTER 7/1/2025"' <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 fille ut and photo pied) <br /> Original Signature: - Date: 12/31/2025 <br /> Note: Maintenance provide mu aintain acc te records of their maintenance contracts, customers, <br /> performance data, and timelines or re • the ontracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130( 4). <br /> DEC/Annual Operation and Maintenance Report Form Rev.6/2022 <br />