Laserfiche WebLink
State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> MICHAEL SHANE WHITE 503-507-6204 <br /> Property Owner: Phone: <br /> 16052 STORMY DR. NE 071E06D02600 <br /> Site Address: Parcel#: <br /> city: SILVERTON County: Marion <br /> Permit#: 555-20-000479-PRMT Start up date if 1st year in use: NA <br /> System Model#: AX2ORT System Serial#: 144091 <br /> Report Year: 2025 Date of Service Performed: 10/28/2025 <br /> Email Address: WHITE.MICHAELSHANE@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> El ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> I] ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> El ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ 0 Is the system failing? <br /> ❑ . Discharge of sewage to the ground surface? <br /> ❑ In Discharge of sewage to drain tiles or surface waters? <br /> ❑ IN 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: Date: <br /> — _ / 12/31/2025 <br /> IXl '�.i,(.( <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 /> ULO Annual Operation and Maintenance Repo!Poem Rev -32022 <br />