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a4 w%3%1-ht.`� <br /> State of Oregon <br /> Department of Environmental Quality <br /> Water Quality Division <br /> DEQ Onsite Program <br /> SialedlOswin <br /> Depnrontot Annual Operation and Maintenance Report Form <br /> away <br /> General Information <br /> Property owner: Annie Lapin Phone#: 541-484-0844 <br /> Site Address: 1840 Brooklake Road City: Salem <br /> County: Marion Permit#: 555-22-007861- PRMT Startup Date: <br /> System Model#: System Serial#: <br /> Service Report Year: 2025 <br /> Onsite wastewater treatment system status: <br /> Yes No <br /> C Was maintenance performed as required by septic system rules(OAR 340-071)and <br /> the manufacturer? <br /> C Is the system operating in accordance with the agent-approved design specifications? <br /> ® C Is the system currently under a service contract with a certified maintenance provider? <br /> Is the system failing? <br /> Yes No <br /> C ® Discharge of sewage to the ground surface <br /> El ® Discharge of sewage to drain tiles or surface waters <br /> C [l Sewage backup into plumbing fixtures <br /> 0 o If yes,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 <br /> this report is grounds for revocation of my certification and/or civil penalties. <br /> Maintenance Provider Name(please print): Nick Gallegos- Best Septic <br /> Certification#: RI 917 Certification Expiration Date: 12/3/2027 <br /> Signature:A24CAfi t. Date: 12/3/2025 <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 agent per OAR 340-071-0345(14). <br /> Annual Operation and Maintenance Report Fonn <br /> Rev. 11/2011 1 I-WQ-055 <br />