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State of Oregon Department of Environmental Quality /7 1.5oo// `-//V <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL Information) <br /> Property Owner: LEANNE & JONNY MARTIN Phone: 503-580-7890 <br /> 2571 QUINABY MEADOW LN. NE 555-05-06678 <br /> Site Address: Parcel#: <br /> City: SALEM County: Marion <br /> Permit#: 063W24AC00602 Start up date if 1st year in use: 10/25/2005 <br /> System Model#: AX2ON System Serial#: 106649 <br /> Report Year: 2025 Date of Service Performed: 12/09/2025 <br /> Email Address: LEANNE@MARTINMETALFAB.NET <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> x❑ ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> _❑ ❑ 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 /> ❑ I] Is the system failing? <br /> ❑ ® Discharge of sewage to the ground surface? <br /> ❑ ® 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 a I "Fe ifi io Expiration: 5/20/2028 <br /> ('This line only can be filled out and photocopied.) (" y / <br /> Original Signature: v 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 /> DEG Annual Operation and LMain enance Report Fan- Rev Pr2022 <br />