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State of Oregon Department of Environmental Quality <br /> I� 6cx�9�2INQ <br /> Annual Operation and Maintenance <br /> FINS <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner MATT & LESLIE SEELY Phone: 503-999-8913 <br /> Site Address: 8305 W H EATLAND RD N Parcel#: 061 E3500500 <br /> city: KEIZER County: Marion <br /> Permit#: 10-04399 Start up date if 1st year in use: 9/8/1 O <br /> System Model#: AX25RT System Serial#: 121894 <br /> Report Year: 2025 Date of Service Performed: 12/09/2025 <br /> Email Address: ml5eely0@c0mca5t.net <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> I] ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> x❑ ❑ 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 /> ❑ III Is the system failing? <br /> ❑ ❑� Discharge of sewage to the ground surface? <br /> ❑ 0 Discharge of sewage to drain tiles or surface waters? <br /> ❑ j 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 cedify 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 ((( 'C If lion Expiration: 5/20/2028 <br /> (*This line only can be filled out and photocopied.) �'�� <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 />