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tpw iD//o-/ <br /> ./`e& State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: DIANA & ALBERTO JACOME Phone: 503-884-4683 <br /> 981 62ND CT. NE 072W21DC01500 <br /> Site Address: Parcel#: <br /> City. SALEM County: Marion <br /> Permit#: 555-24-002559-PRMT Start up date if 1st year in use: NA <br /> System Model#: AX2ORT System Serial#: 143678 <br /> Report Year: 2025 Date of Service Performed: 8/4/2025 <br /> Email Address: CASAJACOME21@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> I] ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> ❑ 0 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 /> •❑ ❑ Is the system failing? <br /> I] ❑ Discharge of sewage to the ground surface? <br /> I] ❑ 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 /> NEW DRAINFIELD SHOWING SIGNS OF FAILURE. INFORMED CUSTOMER AND NEW INSTALLER. <br /> t 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 fi d o nd p•ocopied.) <br /> Original Signature: ,I --_-- —� Date: 12/31/2025 <br /> Note: Ma intenance providers • Y1 maintain accu ate records of their maintenance contracts,customers, <br /> performance data, and timelines o ewing the ontracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-r r 4). <br /> DEO Annual Operation and Maintenance Report Four Rev.62022 <br />