Laserfiche WebLink
State of Oregon Department of Environmental Quality (.Xc/ 0 /NiC —//VO y <br /> Annual Operation and Maintenance <br /> DE;Q. Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: ROY HUSTED Phone: 971-208-8296 <br /> 11577 MCCLELLAN RD SE 092W13DA02600 <br /> Site Address: Parcel#. <br /> City: AUMSVILLE County: Marion <br /> Permit#: 555-23-003670-PRMT Startup date if 1st year in use: 06/04/2024 <br /> System Model#: AX2ORTUV System Serial#: LOGO <br /> Report Year: 2025 Date of Service Performed: 7/28/2025 <br /> Email Address: ROYHUSTED01@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> ❑- - 0 -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 /> i] ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ in Is the system failing? <br /> ❑ ❑Q Discharge of sewage to the ground surface? <br /> ❑ Q Discharge of sewage to drain tiles or surface waters? <br /> ❑ ❑� 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 be filled out and photocopied.) <br /> Original Signature: � / � ' Date: 12/31/2025 <br /> Note: Maintenance providers must maintain accurate records of their maintenance contracts, customers, <br /> performance data, and timelines for renewing the contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEO Ann .,:n vnd Marlenanco Report lr2fril <br />