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State of Oregon Department of Environmental Quality <br /> raA Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: Oregon Resource Association phone: 971-218-7862 <br /> Site Address: 5545 NE Discovery Lane Parcel#: 072W28BC00501 <br /> City: Salem County: Marion <br /> Permit#: 04-09571 Start up date if 1st year in use: 5/7I20O8 <br /> System Models. AX20-1 B System Serial#: 113958 <br /> Report Year: 2025 Date of Service Performed: 12/09/2025 <br /> Email Address: SNEAL@OREGONRESOURCE.ORG <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> l] ❑ 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 /> D ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ • Is the system failing? <br /> ❑ Q Discharge of sewage to the ground surface? <br /> ❑ ID 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 /> -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 Certification Expiration: 5/20/2028 <br /> ('This line only can be filled out and photocopied.) • <br /> Original Signature: (/ 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 /> DEC)Annual operator'and alamla.ance Report Form Rev 6.2022 <br />