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State of Oregon Department of Environmental Quality / 7 & d 7 / 2 - �� v <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: ROGER HALL Phone: 971-239-1960 <br /> Site Address: 5560 JENNICHES LN. SE Parcel#: 082W17D 01502 <br /> City: SALEM County: Marion <br /> Permit#: 13-005034 Start up date if 1st year in use: NA <br /> System Model#: AX2ON-1 B System Serial#: 127428 <br /> Report Year: 2025 Date of Service Performed: 11/19/2025 <br /> Email Address: rogerha1150@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> - u - ❑ _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 /> E ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> El I] Is the system failing? <br /> ❑ Q Discharge of sewage to the ground surface? <br /> ❑ l] Discharge of sewage to drain tiles or surface waters? <br /> ❑ l] 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: 3/28/2026 <br /> (*This line only can be fil °Q and photocopi . <br /> Original Signature: Date: 12/31/2025 <br /> Note: Maintenance providers m st ai in accurate reco s of their maintenance contracts,customers, <br /> performance data, and timelines enew the contracts. hese records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(2 . <br /> DER Annual Operation and Maintenance Report Form Rev.612022 <br />