Laserfiche WebLink
I1—a007y-k- /Flit <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: KALEY & GARRETT TURNEY Phone: 503-507-5640 <br /> 17675 S. ABIQUA RD. NE 061E28CD01000 <br /> Site Address: Parcel#. <br /> City' SILVERTON county: Marion <br /> 13-00731 NA <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: AX2ORT System Serial#: 127678 <br /> Report Year: 2025 Date of Service Performed: 2/20/2025 <br /> Email Address: KALEY013@HOTMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Vas 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 /> E El 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 /> ❑ I] Discharge of sewage to drain tiles or surface waters? <br /> ❑ It Sewage backup into plumbing fixtures? <br /> If you answered"Yes"on the last four questions,was a repair permit obtained? If not, explain: <br /> 1certify thetthisreport 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 /> _eThis line only can be lied out a • to•. <br /> �Original Signature: y Date: 12/31/2025 <br /> ,�/1 <br /> Note: Maintenance provider. mu_t mint,in accurate records of their maintenance contracts, customers, <br /> performance data,and ti ines or ren: 'ng the contracts. These records must be available for inspection upon <br /> request by the agency per OAR 3 0-07 0130(24). <br /> DEC Annual Operation aria Maintenance Re p art Form Rev 62022 <br />