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-TA <br /> State of Oregon Department of Environmental Quality 0l4-ciT l5 N <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: ARLEN STADELI Phone: 503-602-3454 <br /> Site Address: 11863 SILVERTON RD. NE Parcel#: 071W04B000600 <br /> City: SILVERTON County: MARION <br /> UNKNOWN 3/14/2025 <br /> Permit#: Startup date if 1st year in use: <br /> System Model#: AX2ORT System Serial#: LOGO <br /> Report Year: 2025 Date of Service Performed: 10/8/2025 <br /> Email Address: STADELI.ARLEN@GMAIL.COM <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 /> • ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ in Is the system failing? <br /> ❑ NI Discharge of sewage to the ground surface? <br /> ❑ III Discharge of sewage to drain tiles or surface waters? <br /> ❑ El Sewage backup into plumbing fixtures? <br /> If you answered"Yes"on the last four questions,was a repair permit obtained? If not, explain: <br /> 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 n I,' ( eri xpiration: 5/20/2028 <br /> ('This line only can be filled out and photocopied) 111I I�I• <br /> 12/31/2025 <br /> Original Signature: Date: <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 Oper a:,or. 11:1?AainienancP P r,'t Av 02022 <br />