Laserfiche WebLink
/ 2 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: JAMES PRICE Phone: 541-974-4253 <br /> Site Address: 3273 VITAE SPRINGS RD. S. Parcel it. 083W18D0900 <br /> City: SALEM county: Marion <br /> 555-21-006835-PRMT NA <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: PX20RT System Serial#: 145166 <br /> Report Year: 2025 Date of Service Performed: 12/30/2025 <br /> Email Address: JACYGAMBLE@OUTLOOK.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> x❑ ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> Q D 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 /> ❑ ® Is the system failing? <br /> ❑ I] Discharge of sewage to the ground surface? <br /> ❑ • Discharge of sewage to drain tiles or surface waters? <br /> ❑ 0 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): Brandon Pitts - A & B Septic Service <br /> 'Certification#: M 715 'Certification Expiration: 5/20/2028 <br /> ('This line only can be filled out and photocopied.) <br /> Original Signature: <br /> i�a_ 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 /> RFA Annual Wera.ior• r Inrlcnance Report Form Re. it ARP <br />