Laserfiche WebLink
State of Oregon Department of Environmental Quality &- Db 1 C\3tA `QM.. <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: <br /> NANCY & CHRIS POWELL Phone: 503-400-1973 <br /> 8363 WAGNER CT. SE Parcel#: <br /> 082W11D 01100 <br /> Site Address: <br /> City: County: <br /> county: Marion <br /> 555-19-004447-PRMT Start up date if 1st year in use: 5/11/20 <br /> Permit#: <br /> AX2ORT system serial#. 141707 <br /> System Model#. <br /> Report Year: 2025 Date of Service Performed: 10/15/2025 <br /> Email Address: chris.powell.or@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> Q ❑ 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 /> x❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ Q Is the system failing? <br /> ❑ El Discharge of sewage to the ground surface? <br /> ❑ I] Discharge of sewage to drain tiles or surface waters? <br /> ❑ in 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: 3/28/26 <br /> ("This line only can be fi ouiand ph pied.) <br /> 12/31/2025 <br /> Original Signature: Date: <br /> Note: Maintenance providers s aintain accurate ecords of their maintenance contracts, customers, <br /> performance data,and timelines renewing the cont cts. These records must be available for inspection upon <br /> request by the agency per OAR 34 -071.0130(24). <br /> CL n operation I I3.1 <br />