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I S-ol) 1t��15-Dn3tR <br /> -erg, State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: JEREMYAH NELSON 503-508-2905 <br /> Phone: <br /> Site Address: 1509 PINE ST. 061 W34BB02900 <br /> Parcel#: <br /> City: SILVERTON County: Marion <br /> Permit#: 555-17-004531 N/A <br /> Start up date if 1st year in use: <br /> SystemAX2ORT UV 136369 Model#: <br /> System Serial#: <br /> Report Year: 2025 Date of Service Performed: 9/16/2025 <br /> Email Address: JEREMYAHNELSON@YAHOO.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> a ❑ 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 /> O ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ 1.1 Is the system failing? <br /> ❑ a 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 /> sort*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 *Certif at n Expiration: 5/20/2028 <br /> ('This line only can be filled out and photocopied.) <br /> ri' <br /> Original Signature: N I 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 /> DEO Arneal Operation and Mn,rtenance Report FDim Rev 6:2022 <br />