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State of Oregon Department of Environmental Quality <br /> SA Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> PATRICK ZURBRUGG 503-871-7911 <br /> Property Owner: Phone: <br /> 2624 BODHI LN NE 072W13CB00700 <br /> Site Address: Parcel#: <br /> City: SALEM County: Marion <br /> Permit#: 555-23-005743 Start up date if 1st year in use: 03/21/2024 <br /> System Model#: AX2ORT System Serial#: LOGO <br /> Report Year: 2025 Date of Service Performed: 11/4/2025 <br /> Email Address: REDRI DERPAT@YAHOO.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 /> 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 /> ❑ Is the system failing? <br /> ❑ ❑� Discharge of sewage to the ground surface? <br /> ❑ ® 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 /> 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 b- - ed'pit and phot. ..• :: —_--- - <br /> Original Signatur-. - A Alt./a Date: 12/31/2025 <br /> Note: Maintenance provider- must ai -in accurate rec. ds of their maintenance contracts, customers, <br /> performance data,and time nes for r newing the contracts. These records must be available for inspection upon <br /> request by the agency per OA- 40 071-0130(24). <br /> DEQ Annual Operation ano Maintenance R ortap Form Rev e2022 <br />