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&t979/ <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> GARY & MARIE HAMM Phone: 503-364-9818 <br /> Property Owner: _ <br /> Site Address: 459 Cherokee Trail Ln Parcel#: 093W04D03801 <br /> City: Salem county. Marion <br /> Permit it: 11-03038 San up date if 1st year in use: 6/26/20 <br /> System Model#. <br /> AX20-1 A System Serial#. 123654 <br /> Report Year: 2025 Date of Service Performed: 1/28/2025 <br /> Email Address: marieshamm@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> x❑ ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> ❑ ❑ 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 /> ❑ Is the system failing? <br /> El Q Discharge of sewage to the ground surface? <br /> ❑ In 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-Ns feport 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: 3/28/2026 <br /> (*This line only can be out and phot...'ed.) <br /> Original Signature a J At -Th. Date: 12/31/2025 <br /> Note: Maintenance providers fain accurst- records of their maintenance contracts, customers, <br /> performance data,and timelines • ren- ; • the con, acts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0131 ' <br /> DEG Animal Operation act Hai l'lenance Report Farm Rev 62022 <br />