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State of Oregon Department of Environmental Quality /9-and 9/i -m y <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> GARY & JODI EICH 503-781-1270 <br /> Property Owner: Phone: <br /> 16963 SILVER OAKS LN. 061 E29A02200 <br /> Site Address: Parcel#: <br /> City: SILVERTON county: Marion <br /> Permit#: 555-17-005248 3/5/18 <br /> Start up date if 1st year in use: <br /> System Model#: AX2ORT 136810 <br /> System Serial#: <br /> Report Year: 2025 8/29/2025 <br /> P Date of Service Performed' <br /> Email Address: GARYEICH@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> u ❑- Was maintenance performed as required by septic system rules and the manufacturer? <br /> x❑ ❑ 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 /> ❑ MI Is the system failing? <br /> ❑ • Discharge of sewage to the ground surface? <br /> ❑ ❑� 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 /> 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): Nicholas Bohanan - A & B Septic Service <br /> 'Certification#: M 711 C dificat n xpiration: 5/20/2028 <br /> ('This line only can be filled out and photocopied.) <br /> Original Signature: N IC � ���0 (/ <br /> 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 /> DEQ Annual Duel alloy any Manrenaice Report Fnrrn Rev 6/2022 <br />