Laserfiche WebLink
1 1 - bc0 3t1T -TA Q <br /> /'Q, State of Oregon Department of Environmental Quality <br /> SAAnnual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: Aaron Mespelt Phone: 541-798-5018 <br /> Site Address: 12999 Green Acres Ln SE Parcel#. 093W24D003602 <br /> City: Jefferson county Marion <br /> Permit#: 10-04414 Start up date if 1st year in use: NA <br /> System Model#: AX20-1 B System Serial#: 122229 <br /> Report Year: 2025 Date of Service Performed: 9/29/2025 <br /> Email Address: mespeltfamily3@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 /> I] ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> Q 0 Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ I] Is the system failing? <br /> El n Discharge of sewage to the ground surface? <br /> El Q Discharge of sewage to drain tiles or surface waters? <br /> ❑ I] 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 : 3/28/2026 <br /> ('This line only can be fi 4 . t and photocopjor <br /> Original signatures ---AAA ills Date: 12/31/2025 <br /> Note: Maintenance providers i -in accurate records o their maintenance contracts, customers, <br /> performance data, and timelines r ewing the contracts. Th>.e records must be available for inspection upon <br /> request by the agency per OAR 340-07 f 0(24). <br /> DE0 Pomual operation and Maintenance Report Form Rev.62022 <br />