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2-2-io/f2 z.m y <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: SEAN COOPER Phone: 503-949-1516 <br /> 2928 RANGE VIEW LN. 083W08C03401 <br /> Site Address: Parcel#: <br /> City: SALEM County: Marion <br /> 555-19-004007 6/26/20 <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: AX2ORT System Serial#: 140446 <br /> Report Year: 2025 Date of Service Performed: 9/2/2025 <br /> Email Address: SCOOP615@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 /> • ❑ 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 /> El It Discharge of sewage to the ground surface? <br /> ❑ i] 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 /> I-certify hat-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): Coy Morgan - A & B Septic Service <br /> 'Certification#: M 587 *Certification Expiration: 3/28/2026 <br /> ('This line only can be fi edout and p otoco led.) <br /> - ----Original Signe ure ) Date: 12/31/2025 <br /> Note: Maintenance provi ers must naitarn accurate rec Os of their maintenance contracts,customers, <br /> performance data,and time S rene ' the contract . These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130 <br /> DEO Annual Operation and Maintenance Report Form Rev 62022 <br />