Laserfiche WebLink
265 <br /> /sel, State of Oregon Department of Environmental Quality Mal��� / / <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> KEVIN KIKER 503-949-6300 <br /> Property Owner: Phone: <br /> Site Address: 15192 JEFFERSON HWY 99E SE 103W01B01900 <br /> Parcel#. <br /> city: JEFFERSON Marion <br /> County: <br /> Permit#: 555-20-008475 UNKNOWN <br /> Start up date if 1st year in use: <br /> System Model it PRESSURE DISTRIBUTION NA <br /> System Serial#: <br /> Re port Year: 2025 9/29/2025 <br /> P Date m Service Performed: <br /> Email Address: westernkevin@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 /> ❑ ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> x❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ II Is the system failing? <br /> ❑ Discharge of sewage to the ground surface? <br /> ❑ It 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): Cory Morgan - A & B Septic Service <br /> `Certification#: M 587 'Certification Expiration: 3/28/2026 <br /> (*This line only can filled oit and ied.) <br /> Original ----" Date: <br /> 12/31/2025 <br /> Note:Maintenance providers ust maintain a rate records of their maintenance contracts,customers, <br /> performance data,and ti • or renewing th contacts. These records must be available for inspection upon <br /> request by the agency per OAR 34 - 4). <br /> DLO Annual Operation and Maintenance Report Form key 612022 <br />