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I&bokLek3 SPah <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: FRED SAMOILOV Phone: 503-752-7530 <br /> Site Address: 5190 AUBURN RD. Parcel#: 072W29ACO2400 <br /> city: SALEM County: <br /> Marion <br /> 555-15-008223 5tartupdateHistyearinuse: NA <br /> Permit#: <br /> System Model#: AX2ORT system Serial#: 133866 <br /> Report Year: 2025 Date of Service Performed: 12/09/2025 <br /> Email Address: fsamoilov@yahoo.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> •❑ 0 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 /> +❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> El © Is the system failing? <br /> ❑ ® Discharge of sewage to the ground surface? <br /> ❑ ® Discharge of sewage to drain tiles or surface waters? <br /> ❑ ® 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): Brandon Pitts - A & B Septic Service <br /> `Certification#: M 715 *Certfication Expiration: 5/20/2028 <br /> ('This line only can be filled out and photocopied.) <br /> 12/31/2025 <br /> Original Signature: Date: <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 /> DE()Annual Ooeraticn and Mainlanance Ra[att Farm Rev 52022 <br />