Laserfiche WebLink
7 -Co(OZ2-- INQ `1 <br /> 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: SLAV SAMOYLICH Phone: 503-504-1800 <br /> 340 JANICE CT. 105E02DA06500 <br /> Site Address: Parcel#: <br /> City: DETROIT County: Marion <br /> 555-21-004699-PRMT <br /> Permit#: Start up date if 1st year in use: NA <br /> System Model#: AX2ORT System Serial#: 146118 <br /> Report Year: 2025 Date of Service Performed: 10/16/2025 <br /> Email Address: SLAV23@COMCAST.NET <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 /> ❑ El Is the system failing? <br /> El I] Discharge of sewage to the ground surface? <br /> El IN Discharge of sewage to drain tiles or surface waters? <br /> ❑ ❑� Sewage backup into plumbing fixtures? <br /> If you answered"Yes"on the last four questions,was a repair permit obtained? If not, explain: <br /> 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 b; Iled out and phot.. ...i-d <br /> Original Signature ) 1 Date: 12/31/2025 <br /> Note: Maintenance providers us aint.in accurate r-cords of their maintenance contracts, customers, <br /> performance data, and timelines rene .g the cont -cts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-01 • 4). <br /> DEC Annual Operation and Mainrenarairio Report t or Rev Gntazd <br />