Laserfiche WebLink
,/`q, State of Oregon Department of Environmental Quality (96'l N , DaQ l <br /> 414 Annual Operation and Maintenance <br /> rill <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: CARA TAPKEN Phone: 971-772-9570 <br /> Site Address: 11297 PIONEER RD. SE Parcel#: 092E16BC00500 <br /> city: LYONS county: MARION <br /> Permit#: 555-21-000620-PRMT Start up date if 1st year in use: NA <br /> System Model#: PRESSURE DISTRIBUTION System Serial#: NA <br /> Report Year: 2025 Date of service Performed: 12/03/2025 <br /> Email Address: CARATAPKEN@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 /> El ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> El El Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ III Is the system failing? <br /> ❑ M Discharge of sewage to the ground surface? <br /> ❑ 0 Discharge of sewage to drain tiles or surface waters? <br /> ❑ 0 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): COY Morgan - A & B Septic Service <br /> *Certification#: M 587 'Certification Expiration: 3/28/2026 <br /> ('This line only can be filled - t and ph t pied.) <br /> Original Signature: _ Date: 12/31/2025 <br /> Note: Maintenance providers/mist maintain curate recor s their maintenance contracts, customers. <br /> 3 <br /> performance data, and timelme fo renewing the contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340- 71-01 (24). <br /> ❑EQ Annual Opera on and N _•lane_ .a..rn iro Rev rsz02z <br />