Laserfiche WebLink
23- ad nos- A14y <br /> 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: KATHY BRIDGES Phone: 503-365-1235 <br /> Site Address: 6514 HUNSAKER RD SE Parcel#: 092W1600800 <br /> City: TURNER County: Marion <br /> Permit#: 555-16-005813 Start up date if 1st year in use: NA <br /> System Model#: AX2ORT System serial#. 136846 <br /> 2025 Report Year: Date of Service Performed: 7/29/2025 <br /> Email Address: kathylynnebridges@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> la ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> a ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> ❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ 0 Is the system failing? <br /> ❑ IR Discharge of sewage to the ground surface? <br /> ❑ 0 Discharge of sewage to drain tiles or surface waters? <br /> ❑ IS 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 • •. and photocopied.) <br /> el* _,— 12/31/2025 <br /> Original Signe -. Iii�______ Date: <br /> Note: Maintenance providers I ust a stain accurat- records of their maintenance contracts, customers, <br /> performance data,and timelines •r rene • • the co racts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-01 0 4 . <br /> DEG Hnnua,Opprabon and Maintenance Repor ono Rev.(P2022 <br />