Laserfiche WebLink
23 - 00 /b%t / daH <br /> „erg 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: LESTER REITAN Phone: 503-981-5369 <br /> 17070 HARDEL CT. 051 W06AD00600 <br /> Site Address: Parcel#: <br /> city: WOODBURN County: Marion <br /> Permit#: 555-22-004924-PRMT Startup date if 1st year in use: 10/5/2022 <br /> MICROFAST y N/A <br /> System Model#: S stem Serial#: <br /> Report Year: 2025 Date of Service Performed: 9/15/2025 <br /> Email Address: LESREITAN@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not preftll and photocopy checkboxes) <br /> Yes No <br /> •❑ ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> x❑ E Is the system operating in accordance with the agent-approved design specifications? <br /> ❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ❑� Is the system failing? <br /> ❑ I] Discharge of sewage to the ground surface? <br /> ❑ • 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 /> 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: ti? Date: 12/31/2025 <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 /> DEO Annual Operation and Maintenance Report onn Rev.8i2022 <br />