Laserfiche WebLink
State of Oregon Department of Environmental Quality ,2Y X//s- iNGY <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> KYLE HAMAR 971-335-0078 <br /> Property Owner: Phone: <br /> Site Address: 7633 DOVICH LN. SE Parcel#: 082730DB00102 <br /> City. SALEM Marion <br /> County: <br /> Permit#: 555-23-006762 11/22/23 <br /> Start up date if 1st year in use: <br /> System Modeltt: SINGULAR NA <br /> s <br /> YSystem Serial#: <br /> Report Year: 2025 Date of Service Performed: 10/27/2025 <br /> Email Address: KYLE.HAMAR@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 /> I] ❑ 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 /> ❑ I] Discharge of sewage to the ground surface? <br /> ❑ IN Discharge of sewage to drain tiles or surface waters? <br /> ❑ NI 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' 3/28/26 <br /> ('This line only can b- e• out and photoco.'-d.) <br /> Original Signature: _ AltDate.• 12/31/2025 <br /> Note: Maintenance providers flaint='n accurate r= ords of their maintenance contracts, customers, <br /> performance data, and timelines • -newi he contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(2, <br /> DEO Annual Operation and Maintenance Report Porn Rev 672022 <br />