Laserfiche WebLink
State of Oregon Department of Environmental Quality I 1 -bo\o5 SIv Q <br /> Annual Operation and Maintenance <br /> DEQ� Report Form <br /> General Information (Complete ALL information) <br /> Trinity Lutheran Church (503) 235-1777 <br /> Property Owner: Phone: <br /> 15534 E Marquam Rd 061 E06 01500 <br /> Site Address: Parcel#: <br /> Mt Angel Marion <br /> City: County: <br /> 17-001051-INQ <br /> Permit#. Start up date if 1st year in use: <br /> System Model#: System Serial#: <br /> 2025 11/3/2025 <br /> Report Year: Date of Service Performed: <br /> Email Address: office.septech@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> ❑x ❑ 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 /> ❑x ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ • Is the system failing? <br /> ❑ Discharge of sewage to the ground surface? <br /> ❑ ® Discharge of sewage to drain tiles or surface waters? <br /> ❑ E 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). Joseph Audas - Septic Technologies <br /> 'Certification#: RM 259 'Certification Expiration 10/19/27 <br /> (*This line only can be filled qut and photocopied.) <br /> r1��- ` 12/31/2025 <br /> Cr"' <br /> ^ <br /> Original Signature: V _fr. Date: <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 /> DEC)Arnuai ration am Pl. nte'alce Reoct f a-- Rev 3:2022 <br />