Laserfiche WebLink
/7000CF05— Y44 <br /> State of Oregon Department of Environmental Quality <br /> SAnnual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: Steve Hoskins Phone: 503-362-8065 <br /> 1952 Cole Rd S 083W28BC00600 <br /> Site Address: Parcel#: <br /> City- Salem county: Marion <br /> Permit#: 06-102812 Start up date if 1st year in use: NA <br /> System Model#: AX20-1 A System Serial#: 104571 <br /> Report Year: 2025 Date of Service Performed: 12/12/2025 <br /> Email Address: stevehoskinssr@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> LJ ❑ 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 /> x❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ 0 Is the system failing? <br /> ❑ ❑� Discharge of sewage to the ground surface? <br /> ❑ Q Discharge of sewage to drain tiles or surface waters? <br /> ❑ El 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 cermry 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 fitte toco.ied) <br /> Original Signature: �+ ' i Date: 12/31/2025 <br /> Note: Maintenance providers m. t intain accurate ecords of their maintenance contracts, customers, <br /> performance data,and timelines for re : .ing the cont :cts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-01 4 . <br /> DEC:Annual Operation and Maintenance Report=arm Rev 5.2122 <br />