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State of Oregon Department of Environmental Quality <br /> 11 O aC7zg— IN <br /> �31 Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> PropertyOwner: KEVIN BARBER Phone: 503-932-7664 <br /> 315 7th St. Parcel#: <br /> Site Address: <br /> City: Scotts Mills County: Marion <br /> Permit#: 07-00551 Start up date if 1st year in use: NA <br /> System Model#: <br /> AX20-1 A System Serial#: 111993 <br /> Report Year: <br /> 2025 Date of Service Performed- 8/21/2025 <br /> Email Address: kevinlbarber@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> ❑ ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> I] ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> Q ❑ 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 /> ❑ III Discharge of sewage to drain tiles or surface waters? <br /> ❑ III 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: <br /> 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 atio 1 Maintenance Renee .em Rev 3:2022 <br />