Laserfiche WebLink
17 acoci3K- I NQ <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> p <br /> DEQ <br /> Report Form <br /> General Information (Complete ALL information) <br /> Property owner: AARON REOPELLE Phone: 503-480-9049 <br /> Site Address: 2827 SALAMANDER RD. SE 103W01 00400 <br /> Parcel#: <br /> city: JEFFERSON Marion <br /> County: <br /> Permit#: 555-15-006768 NA <br /> Start up date if 1st year in use: <br /> AX2ON 132342 <br /> System Model#: <br /> System Serial#: <br /> Report Year: 2025 11/10/2025 <br /> Date of Service Performed: <br /> Email Address: moparmanar@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> - n ❑ -Was maintenance performed as required by septic system rules and the manufacturer? <br /> x❑ ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> i] ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ i] Is the system failing? <br /> ❑ ❑� 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 W. M 587 *Certification Expiration: 3/28/2026 <br /> (*This line only can b od'cu an ie ----- <br /> Original Signature: Date: 12/31/2025 <br /> Note: Maintenance providers ust aintain accurate r ords of their maintenance contracts, customers, <br /> performance data, and timelines for newing the contr ts. These records must be available for inspection upon <br /> request by the agency per OAR 340-07 130(24). <br /> DEC)Annual Operation and Maintenance React l orm Rev fi z 22 <br />