Laserfiche WebLink
- <br /> State of Oregon Department of Environmental Quality /7 (/(/ O £51 /A4 <br /> SA1 Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: Robert Lewis Phone: 503-551-8425 <br /> 10443 Brick Rd Parcel#: <br /> 092W11A 01330 <br /> Site Address: <br /> City. Turner county: Marion <br /> Permit it: 08-07344 Start up date if 1st year in use: 1/5/2009 <br /> System Model#: AX20-1 B System Serial#: 116076 <br /> Report Year: 2025 Date of Service Performed: 12/09/2025 <br /> Email Address: blewisfam1@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 /> El ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> El ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> El ❑U Is the system failing? <br /> ❑ MI Discharge of sewage to the ground surface? <br /> ❑ ® Discharge of sewage to drain tiles or surface waters? <br /> ❑ Ei Sewage backup into plumbing fixtures? <br /> If you answered"Yes"on the last four questions,was a repair permit obtained? If not,explain: <br /> f derfify thatthfa 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 be . • t and photocopied.) <br /> Origin- . • -. l - <br /> A -- Date: 12/31/2025 <br /> Note: Maintenance providers mu t maintain ac urate records of their maintenance contracts,customers, <br /> performance data, and timelin- enewing th contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-07 -• + 4). <br /> DEQ Annual Operation aria Ma✓rte,a ern-Report For Rev e/2022 <br />