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aLt-rw`13 L la`s <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenanc - <br /> DEQ Report Form <br /> General Information (Complete ALL Information) <br /> Property Owner. Olexy Stanko Phone: 503-999-3835 <br /> Site Address: 2865):]temMe'Lane S 6-T[%m t V1c1/4, ti.,1S Parcel#: <br /> City: Salem OR 97306 County: Marion <br /> Permit#: 555-23-000699 Start up date if 1st year in use: <br /> System Model#: AX-157745 RTU149i69 <br /> System serial* <br /> Report Year. 2025 Date of Service Performed: P a- a;("•— <br /> Email Address:OffiCeOaOSr1w.COm <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkbo es) <br /> Yes No <br /> 14 0 Was maintenance performed as required by septic system rules and the manufacturer? <br /> A ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> IQ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ® Is the system failing? <br /> ❑ gi Discharge of sewage to the ground surface? <br /> ❑ N: Discharge of sewage to drain tiles or surface waters? <br /> ❑ 5f_Sewage backup Into plumbing fixtures? <br /> If you answered"Yes'on the last four questions,was a repair permit obtained? If not,explain: <br /> icertify ihatiMsreport 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): Matthew I andry American On Site <br /> 'Certification it: RM 17 Certification Expiration: 04/24/27 <br /> ('this line only can be fill out and ph Plat) <br /> d 7rce9— AC <br /> Original Signature: // < Date: <br /> Note:Maintenance oviders must rt> in records of their maintenance contracts,customers, <br /> performance.data,and timelines for ren a contracts. These records must be available for inspection u n <br /> request by the agency per OAR 340-0 1-0130(24). <br /> 6CP al:.'f . rF. h .r F. Rv, I222 <br />