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State of Oregon Department of Environmental Quality 202 6(" 27/�1/A/ <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL Information) <br /> Property Owner: ROXANNA HOWELL Phone: 541-974-4224 <br /> Site Address: 10456 LAKE DR. Parcel#: 093W 10602900 <br /> city: SALEM county: Marion <br /> Permit#: 555-21-004709-PRMT Start up date if 1st year in use: 10/19/21 <br /> System Model#: AX25RT System Serial#: 146251 <br /> Report Yea 2025 Date of Service Performed: 12/31/2025 <br /> Email Address: ROXANNAMHOWELL@yahoo.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> Lt ❑- Wasmaintenance performed as required by septic system rules and the manufacturer? <br /> 0 ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> i ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ Q Is the system failing? <br /> ❑ ® Discharge of sewage to the ground surface? <br /> ❑ Q 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): Cory Morgan - A & B Septic Service <br /> 'Certification#: M 587 'Certi tion Expiration: 3/28/2026 <br /> ('This line only can be filled out and photocopied.) CT� <br /> Original Signature: Date: <br /> 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 /> DLO)Annual Operation and Maintenance Report I orm Rev.620^_2 <br />