Laserfiche WebLink
25 000gVP ►Nay <br /> / X 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: JEANNE BECKER Phone 503-250-2623 <br /> Site Address: 127 GATES HILL RD Parcel# 093E26C 01300 <br /> City: GATES County: Marion <br /> 555-18-008073 Start up date if 1st year in use: 5/17/22 <br /> Permit#: <br /> System Model#: AX2ORT System Serial#: 145566 <br /> Report Year: 2025 Date of Service Performed: 9/19/2025 <br /> Email Address: MOMBECKER7@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> • ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> Q El Is the system operating in accordance with the agent-approved design specifications? <br /> Q ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ • Is the system failing? <br /> ❑ it Discharge of sewage to the ground surface? <br /> ❑ ❑� 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 ce@gy 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 Expiration: 3/28/26 <br /> ('This line only can be filled nd photocopi d.) <br /> Ongina igna ure: - 12/31/2025 <br /> Date: <br /> Note: Maintenance providers must tai ccu to records of their maintenance contracts,customers, <br /> performance data, and timelines for renewing t ntracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> oFn , 0l :II., <br />