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-erg, State of Oregon Department of Environmental Quality /7— (19 74,f-/47 <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: EMILY DUERST Phone: 503-932-1326 <br /> Site Address: 2240 CLEARLAKE RD. NE Parcel#: 063W24CO2900 <br /> ci SALEM County: Marion <br /> v <br /> Permit#: 11-04238 Start up date if 1st year in use: 9/30/11 <br /> System Model#: AX2ORT system serial t 123764 <br /> Report Year: 2025 Date of Service Performed: 1 1/4/2025 <br /> Email Address: EDUERST86@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not preffll and photocopy checkboxes) <br /> Yes No <br /> I ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> Q ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> Q ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ IN Is the system failing? <br /> ❑ M Discharge of sewage to the ground surface? <br /> ❑ 0 Discharge of sewage to drain tiles or surface waters? <br /> D II 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 t ra-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 7 *Certification •'ration: 3/28/2026 <br /> (*This line only Tn be II out and photocopi=• _ <br /> �Ir Date: 12/31/2025 <br /> Original Signature: I <br /> Note: Maintenance provide must aintain -. urate v-cords of their m-' tenance contracts,customers, <br /> performance data,and time) s to renewing th- -• tracts. These re • 's must be available for inspection upon <br /> request by the agency per OA -071-0130(24). <br /> DEO Annual Operation and Maintenance naoort Form Rev 6,2022 <br />