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/7 00757-0 <br /> 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: Ron Comstock Phone: 503-798-7206 <br /> Site Address: 6244 Rambeau Lane SE 082W04A006000 <br /> Parcel#: <br /> City: Salem Marion <br /> County: <br /> 05-05567 <br /> Permit#: Start up date if 1st year in use: NA <br /> AX20-1 A 105969 System Model#: <br /> System Serial#r <br /> Report Year: 2025 Date of Service Performed: 3/31/2025 <br /> Email Address: rjcomstock@photmall.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> u 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 /> i] ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ❑� Is the system failing? <br /> ❑ Q Discharge of sewage to the ground surface? <br /> ❑ ni 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 /> (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: 3/28/26 <br /> (*This line only can be fille• •ut and p oto ••ied.) <br /> iI 12/31/2025 <br /> Original Signature: IS A � Date: <br /> Note: Maintenance •ro ••_ - � aintain a maintenance contracts,customers, <br /> performan •- -, and timelines •r renewing the contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> AoAnnual.,pashun ano .unnance report Roan <br />