Laserfiche WebLink
d3-DClbB1 --I n\? <br /> / tz 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: ADAM SNYDER Phone: 406-381-3459 <br /> 360 JANICE CT. Parcel#: 105E02DA06700 <br /> Site Address: <br /> City: <br /> DETROIT County: Marion <br /> 555-16-006685-SEP Start up date if 1st year in use: NA <br /> Permit#: <br /> AX20RT System Serial#: 147702 <br /> System Model#: <br /> Report Year: 2025 Date of Service Performed: 10/16/2025 <br /> Email Address: adamtsnyder@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> ❑ ❑---Was maintenance performed as required by septic system rules and the manufacturer? <br /> Q ❑ 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 /> ❑ 0 Discharge of sewage to the ground surface? <br /> ❑ ❑� 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 /> tbertVtlfatthitteport 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 d gat and ph pied.) <br /> Original Signature: <br /> Date: 12/31/2025 <br /> Note: Maintenance providers ust m ntain accura records of their maintenance contracts, customers, <br /> performance data, and timelin renewing the co tracts. These records must be available for inspection upon <br /> request by the agency per OAR 340 71-0130(24). <br />