Laserfiche WebLink
z 3 aza77 <br /> State of Oregon Department of Environmental Quality <br /> ral1 Annual Operation and Maintenance <br /> /1"-DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: JESSICA & NICHOLAS CRAPSER Phone: 360-562-5622 <br /> Site Address: 8815 WEST STAYTON RD. SE Parcel#: 082W36C 02300 <br /> ci AUMSVILLE County: Marion <br /> h: <br /> Permit#: 555-21-006876-PRMT-01 Start up date if 1st year in use: 8/2/22 <br /> System Model#: AX2ORT System Serial#: 145028 <br /> Report Year: 2025 Date of Service Performed: 9/23/25 <br /> Email Address: JESSIE.CRAPSER@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 /> Q ❑ 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 /> ❑ It Is the system failing? <br /> ❑ El Discharge of sewage to the ground surface? <br /> ❑ 0 Discharge of sewage to drain tiles or surface waters? <br /> ❑ RI Sewage backup into plumbing fixtures? <br /> If you answered"Yes"on the last four questions,was a repair permit obtained? If not,explain: <br /> 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 b lied ut and ph asar'9i tl. / <br /> Origi natur -- -- Date: <br /> 12/31/2025 <br /> Note: Maintenance provide us maintain a to ecords of their maintenance contracts,customers, <br /> performance data,and timelines or renewing the contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEC Annual Operation and Maintenance Report FDrrn Rev.6/2022 <br />