Laserfiche WebLink
.- State of Oregon Department of Environmental Quality a.3- w\\tB1 io(_)2 ` <br /> rli Annual Operation and Maintenance <br /> `DEEQQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: SCOTT SMITH Phone: 971-718-0487 <br /> Site Address: 6324 JACINDA LN S Parcel#: 084W24B 01100 <br /> City: SALEM county: Marion <br /> 555-20-005561-PRMT San up date if 1st year in use: 6/21/22 <br /> Permit#: <br /> System Model#: 2ORT System Serial#. 147359 <br /> Report Year: 2025 Date of Service Performed: 5/2/2025 <br /> Email Address: SS0832103@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> Q ❑ 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 /> ❑ El Is the system failing? <br /> 0 • Discharge of sewage to the ground surface? <br /> ❑ III 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): Cory Morgan - A & B Septic Service <br /> 'Certification#: M 587 *Certification Expiration: 3/28/2026 <br /> ('This line only can •- filled out an• •hotocopied.) <br /> /I1 A _ 12/31/2025 <br /> Original Signature: .. ala Date: <br /> Note: Maintenance provider- st maintain a, urate records of their maintenance contracts,customers, <br /> performance data, and timel for renewing t' - contracts. These records must be available for inspection upon <br /> request by the agency per 0..: 340-071-0130(2 ). <br /> DEC-rnual(Morahan and Ivlainler ante Renor. - Rev 1E2022 <br />