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aa-EQ-IS33-tea <br /> ../-`c_. State of Oregon Department of Environmental Quality <br /> rtii Annual Operation and Maintenance <br /> Ira <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> RICHARD MOORE 503-329-2768 <br /> Property Owner: Phone: <br /> 17496 ABIQUA RD. NE 061 E28CB00600 <br /> Site Address: Parcel#: <br /> City: SILVERTON County: Marion <br /> 10-05263 Start up date 1st year in use: <br /> Permit#: NA <br /> System Model#: AX2ORT System Serial it: 142920 <br /> Report Year: 2025 Date of Service Performed: 9/10/2025 <br /> Email Address: RI CHARDMOORE7765@COMCAST.NET <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 /> Q ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> Q 0 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 /> ❑ Q Discharge of sewage to drain tiles or surface waters? <br /> ❑ Q 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 a fication Expiration: 5/20/2028 <br /> (*This line only can be filled out and photocopied.) i <br /> Original Signature: N 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 operation arm Maintenance Repon Reim Rev 62022 <br />