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/`Q State of Oregon Department of Environmental Quality / g" P5/ /44 <br /> ►�ii4 Annual Operation and Maintenance <br /> reilli <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: <br /> DENNIS & SHERRYL LAMM Phone: 503-585-4587 <br /> 5695 CULVER DR. SE Parcel#: 082W04B 01200 <br /> Site Address: <br /> City: SALEM County: Marion <br /> Permit It: Start Start up date if 1st year in use: NA <br /> System Model#: AX2ON System Serial#. 116604 <br /> Report Year: 2025 - Date of Service Performed: 12/31/2025 <br /> Email Address: NA <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> x❑ [3 Was maintenance performed as required by septic system rules and the manufacturer? <br /> x❑ ❑ 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 /> ❑ I] Is the system failing? <br /> ❑ 0 Discharge of sewage to the ground surface? <br /> ❑ Q Discharge of sewage to drain tiles or surface waters? <br /> ❑ MI 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: 03/28/2026 <br /> ('This line only can be -d o k t and phot....ied <br /> all <br /> Original Signature: - �VA,...__ Date: <br /> 12/31/2025 <br /> Note: Maintenance providers ! -t mainta ate records of their maintenance contracts, customers, <br /> performance data,and timelines for renew* - contracts, These records must be available for inspection upon <br /> request by the agency per OAR 340-071-01 r ,). <br /> DEC Ann.ial Operation and PJainsnase Eeport For" Rev 6:2022 <br />