Laserfiche WebLink
&I- 7 53 - NQ y <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: CONNIE L. FLOWERS phone: 503-991-6906 <br /> 7807 ALBUS RD. 081 W30D01200 <br /> Site Address: Parcel#: <br /> city: AUMSVILLE county: Marion <br /> Permit#: 555-19-004608 Start up date if 1st year in use: 12/11/19 <br /> System Model#: AX2ORT System Serial#: 140266 <br /> Report Year: 2025 Date of Service Performed: 1/23/2025 <br /> Email Address: )C2flowers@wvl.cOnl <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> x❑ ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> x❑ ❑ 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 /> ❑ • Is the system failing? <br /> ❑ Q 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): MAGNUM MILLER - A & B Septic Service <br /> *Certification#: RM 174 *Certification Expiration: 4/24/27 <br /> (*This line only can be filled ou and photocopied) <br /> Original Signature: Date: 12/31/2025 <br /> Note: Maintenance pr iders must maintain accurate records of their maintenance contracts,customers, <br /> performance data,and timelines for renewing the contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> OLO A )i ' ation d. l ri ienanry ain't I , in Re‘, 2)L2 <br />