Laserfiche WebLink
State of Oregon Department of Environmental Quality ,e DD, yI V tD,� <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: STEVE NICKODEMUS Phone: 208-597-5854 <br /> site Address: 15320 MARQUAM RD. Parcel# 061 W 12A00100 <br /> city: MT. ANGEL County: Marion <br /> Permit#: 555-15-005492 Start up date if 1st year in use: 8/5/16 <br /> System Model#: AX2ORT System Serial#: 133939 <br /> Report Year: 2025 Date of Service Performed: 1/28/2025 <br /> Email Address: UNKNOWN <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> I] ❑ 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❑ El Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ It Is the system failing? <br /> ❑ i] Discharge of sewage to the ground surface? <br /> ❑ it Discharge of sewage to drain tiles or surface waters? <br /> ❑ MI 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): MAGNUM MILLER - A & B Septic Service <br /> 'Certification#: RM 174 *Certification Expiration: 4/24/27 <br /> ('This line only can be filled out and p otocopie <br /> Original Signature: Date: 12/31/2025 <br /> Note: Maintenance p iders must maintain accurate records of their maintenance contracts,customers, <br /> performance data, an 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 /> ULQ Annual Ooeration and MainteranRe Report' ain Rev 62022 <br />