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I-7 -0009943/- /NQ <br /> f`Sk, State of Oregon Department of Environmental Quality <br /> rill Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: FLOYD SIPPEL Phone: 503-932-0946 <br /> Site Address: 6215 LAKESIDE DRIVE NE parcel#: 062W31A01400 <br /> city: SALEM county: Marion <br /> Permit#: 05-08218 Start up date if 1st year in use: 11/17/05 <br /> System Model it: X20N System Serial it: 106793 <br /> Report Year: 2025 Date of Service Performed: 12/09/2025 <br /> Email Address: FLOYD@SIPPELWELLDRILLING.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> ▪ El 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 /> E ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ IN Is the system failing? <br /> El ® 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 it: M 711 C�ertifica n xpiration: 5/20/2028 <br /> ('This line only can be filled out and photocopied.) <br /> If 1(I U 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 /> JEt :pe�atn r NrnIce Fpu .--on, Rev62022 <br />