Laserfiche WebLink
C23-COOSSOrt at? <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL Information) <br /> PropertyOwner: SANTIAM CENTER Phone: (503) 315-4294 <br /> Site Address: 11656 SUBLIMITY RD SE Parcel#: T8S R1W S33C TL700 <br /> city: STAYTON county: MARION <br /> Permit#: 102462 - OLD WPCF PERMIT Start up date if 1 st year in use: <br /> System Modem: RECIRCULATING GRAVEL FILTER System Serial#: <br /> Report Year: 2025 Date of Service Performed: 11/13/2025 <br /> Email Address: office.septech@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> O 0 Was maintenance performed as required by septic system rules and the manufacturer? <br /> El ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> I] 0 Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ a Is the system failing? <br /> ❑ IM Discharge of sewage to the ground surface? <br /> O ® Discharge of sewage to drain tiles or surface waters? <br /> ❑ II 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(ple?prin�y Richard Taylor - Septic Technologies <br /> *Certification#: RM7 ) / *Certification Expiration: 03/27/2027 <br /> ('This line only can be filled outaand,ptlotocopi ) <br /> Original Signature: •-. ' Date: 12/31/2025 <br /> Note: Maintenance providers must ma' in 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 /> c..-- <br />