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/'Q, State of Oregon Department of Environmental Quality si•W 0///' //A/Q y <br /> riik Annual Operation and Maintenance <br /> Pa <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: KEITH HART Phone: 503-551-6085 <br /> 5377 BALLYNTYNE CREEK LN. S 083W17B 02200 <br /> Site Address: Parcel#: <br /> City: SALEM County: Marion <br /> Permit#: 555-22-001448-PRMT Start up date if 1st year in use: 3/2/2023 <br /> System Model#: AX2ORT System Serial#: 147016 <br /> Report Year: 2025 Date of Service Performed. 10/10/2025 <br /> Email Address: HARTK2012@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> a- ❑- 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❑ 0 Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ] Is the system failing? <br /> El I] Discharge of sewage to the ground surface? <br /> ❑ I] 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 /> *Cert tion#: M 587 *Certification Expiration: 3/28/2026 <br /> (*This line only can be[�etl out and photocopied.) <br /> Original Signature: 1/\ -a, C ) Date: 1 Z/31/2025 <br /> Note: Maintenance provid s mus in/tain accurat records of their maintenance contracts, customers, <br /> performance data, and finishre wing the cortracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071- 24 <br /> DEQ Annual Operation and Maintenance Repo'Form Rev.62022 <br />