Laserfiche WebLink
,l State of Oregon Department of Environmental Quality / i M Z6D-- IN Q <br /> Annual Operation and Maintenance <br /> Willi <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: DANIEL ARCHER 971-208-1998 <br /> Phone: <br /> Site Address: 1674 63rd Ave NE 072W21A01300 <br /> Parcel#: <br /> City: County: <br /> . Marion <br /> County. <br /> Permit#: 09-02011 N/A <br /> Start up date if 1st year in use: <br /> Delta WhiteWater <br /> System Model#: System Serial#: N/A <br /> Report Year: 2025 Date of Service Performed: 8/4/2025 <br /> Email Address: DDARCHER@YAHOO.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> O ❑ 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 /> Q ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ MI Is the system failing? <br /> ❑ D Discharge of sewage to the ground surface? <br /> ❑ Q Discharge of sewage to drain tiles or surface waters? <br /> ❑ Q 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 fit out and photocopied.) <br /> Original Signature: Date: 12/31/2025 <br /> Note: Maintenance providers p3ist maint in a curate records of their maintenance contracts,customers, <br /> performance data, and timelines for renew g the contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-01 (24). <br /> DEC/Annual Operation and Maintenance Report Form Rev.6/2022 <br />