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/g, State of Oregon Department of Environmental Quality 2& al,1-iob ` <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> CA5C la-aq-a5 <br /> General Information (Complete ALL information) <br /> Property owner: GLENN & ARLENE PFAU Phone: 503-910-4333 <br /> Site Address 6292 LAKE LABISH RD. NE Parcel it: 062W32B001900 <br /> city: SALEM county: MARION <br /> Permit#: 96-82712 Start up date if1st year in use: 8/27/25 <br /> System Model#: AX2ORT System Serial#: LOGO <br /> Report Year: 2025 Date of Service Performed: <br /> Email Address: KENEPFAU@YAHOO.COM <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 /> El ❑ 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 /> ❑ NI Discharge of sewage to drain tiles or surface waters? <br /> ❑ I] 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 5� 'Certification Expiration: 3/28/2026 <br /> (*This line only can be fi ed o t and 5 pi-d.) <br /> Original Signature: Date: 12/31/2025 <br /> Note: Maintenance provide mu m.intain accurate -cords of their maintenance contracts,customers, <br /> performance data, and timelin r-'ewing the contr- ts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-1 • 24). <br /> DEO Annual Operation and Manlenance Renard Form Rev 62022 <br />