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-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: Dianna Odman Phone: 503-873-2260 <br /> Site Address: 14550 NE Nikita Lane Parcel#: 061 W25C001002 <br /> City: Silverton county: Marion <br /> Permit#: 12-03559 Start up date if 1st year in use: NA <br /> System Model#: AX2ORTUV System Serial#: 126325 <br /> Report Year: 2025 Date of Service Performed: 8/22/2025 <br /> Email Address: busymomofbaron@gmaiI.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 /> x❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ Q Is the system failing? <br /> ❑ 0 Discharge of sewage to the ground surface? <br /> ❑ El 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 certifylhatlhiS 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): Brandon Pitts - A & B Septic Service <br /> 'Certification#: M 715 'Certification Expiration: 5/20/2028 <br /> ('This line only can be filled out and photocopied.) Jan <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 /> DEO Annual Operation and Maintenance Report Fonn Rev 62022 <br />