Laserfiche WebLink
_erg State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> rill <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: EDITH PANIAGUE FRANCO Phone: 971-255-7288 <br /> 5676 WACONDA RD. NE Parcel#: 062W04C000400 <br /> Site Address: <br /> city: SALEM County: Marlon <br /> 12-04986 Start u date if 1st year in use: 10/11/2012 <br /> Permit it: P <br /> SINGULAIR 960 Sysemsedalu. 900284QU <br /> System Model#. <br /> Report Year: <br /> 2025 Date of Service Performed: 5/16/2025 <br /> Email Address: EDITH@LUCIANOSFLOORS.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> Q ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> Q 0 Is the system operating in accordance with the agent-approved design specifications? <br /> x❑ 0 Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ 10 Is the system failing? <br /> 0 10 Discharge of sewage to the ground surface? <br /> ❑ o Discharge of sewage to drain tiles or surface waters? <br /> ❑ It Sewage backup into plumbing fixtures? <br /> If you answered'Yes"on the last four questions,was a repair permit obtained? If not,explain: <br /> - f 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 <br /> �.61-• • - • _ a-., —"'g <br /> Original Signatu ‘ Date: 12/31/2025 <br /> Note: Maintenance provid- it main r-in accurate recur. i of their maintenance contracts,customers, <br /> performance data,and ti - - or rent.-'ng the contracts. -se records must be available for inspection upon <br /> request by the agency per • - i 0-071-1 0(24). <br /> DER Anneal Operation and M amtena n i:e.Repor FRn➢ Rev 6/2022 <br />