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State of Oregon Department of Environmental Quality 251 002 11 7 - I N Q 1 <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL Information) <br /> Property owner: SCOTT SALAZAR Phone: 971-719-6330 <br /> Site Address: 9493 GOLF CLUB RD SE Parcel u: 091 W04B002200 <br /> City: AUMSVILLE County: Marion <br /> Permit it: UNKNOWN Start up date if 1st year in use: 01/t t/2024 <br /> System Model it PRESSURE DISTRIBUTION System serial#: N/A <br /> Report Year: 2025 Date of Service Performed: 8/25/2025 <br /> Email Address: SCOTT.SALAZAR88@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 /> x❑ ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> x❑ El Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ IU Is the system failing? <br /> ❑ Q Discharge of sewage to the ground surface? <br /> ❑ ® Discharge of sewage to drain tiles or surface waters? <br /> ❑ MI 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 tertifi,ation Expiration: 5/20/2028 <br /> (*This line only can be filled out and photocopied.) �I �,y(I'1 <br /> Original Signature: I 1 I-'` 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 Annual Operation and Maintenance Report Form Rev 6t2622 <br />