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State of Oregon Department of Environmental Quality , 23—Dtv /D/ 9 0 l-Y)( <br /> Annual Operation and Maintenance <br /> DEQ' Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: SARA DUNCAN Phone: 503-949-5413 <br /> Site Address: 2832 STRONG RD SE Parcel#: 083W12B002300 <br /> City: SALEM Marion <br /> County: <br /> Permit#: 555-19-000685-PRMT Start up date if 1st year in use: UNKNOWN <br /> System Model#: AX2ORT System Serial#: 137821 <br /> Report Year: 2025 . 1/7/2025 <br /> P Date of Service Performed. <br /> Email Address: SBDUNCA@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 /> I] ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> E ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ IN Is the system failing? <br /> ❑ Q Discharge of sewage to the ground surface? <br /> ❑ Q Discharge of sewage to drain tiles or surface waters? <br /> ❑ In 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 filled out and photocopied.)- <br /> Original Signature: / 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 /> DEO Annual p. :on and Pt ,.non Ncpol o.,v Nov.6.1022 <br />