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/7 DOl <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Progeny owner: SCOTT & MARGARET DANIELS 503-881-1238 <br /> Phone: <br /> Site Address: 4165 SUNSET RIDGE ROAD Parcel#: 084W12D 04300 <br /> City: SALEM Marion <br /> county. <br /> Permit#: 555-08-03874 6/12/2008 <br /> Start up date if 1st year in use: <br /> AX2ON 114838 System Model#: <br /> System Serial#. <br /> Report Year: 2025 Date of Service Performed: 12/12/2025 <br /> Email Address: SDANIELS@ALDRICHADVISORS.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> )(I Li Was maintenance performed as required by septic system rules and the manufacturer? <br /> I] ❑ 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 /> ❑ 0 Is the system failing? <br /> ❑ IrI Discharge of sewage to the ground surface? <br /> ❑ 0 Discharge of sewage to drain tiles or surface waters? <br /> ❑ 0 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 , ed • t and photoc..ied.) <br /> Original Sign- �� -4 . - _ Date: 12/31/2025 <br /> Note: Maintenance providers m�ain -'n accurate reco .s of their maintenance contracts, customers, <br /> performance data, and timelines • enewi = the contracts These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130 <br /> DECa opeiatian lel.Rnrenance R_per Form Rev 52022 <br />