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-. State of Oregon Department of Environmental Quality <br /> r.3 - 0-ob &- WQ9l <br /> _er <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: ALLEN SKOMIAL Phone: 248-379-9595 <br /> Site Address 13722 EDISON HEIGHTS LN. NE Parcel#: 071 W11B00600 <br /> City. SILVERTON County: Marion <br /> Permit#: 555-21-004559-PRMT Start up date if 1st year in use: N/A <br /> System Model#: AX2ORT System Serial#: 146961 <br /> Report Year: 2025 Date of Service Performed: 10/8/2025 <br /> Email Address: BLUENSILVER01@MSN.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> -L❑ ❑ 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 /> x❑ ❑ 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 /> ❑ 0 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 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 C rtificaf n xpiration: 5/20/2028 <br /> (*This line only can be filled out and photocopied) �j <br /> Original Signature: Date: <br /> 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 Annual Operation end ti•lamtenence Report;oral Rea d 2022 <br />