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5-002 ( '1 I - (�Q`1 <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> riga <br /> DEQ Report Form <br /> General Information (Complete ALL Information) <br /> Property owner: BRIAN RICKMAN Phone: 503-504-8702 <br /> Site Address: 4347 WINDY WAY NE Parcel#: 071E06D001000 <br /> City. SILVERTON County: Marion <br /> Permit#: Start Start up date if 1st year in use: NA <br /> System Model#: AX2ORT System Serial#: 139095 <br /> Report Year: 2025 Date of Service Performed: 9/5/2025 <br /> Email Address: BMR535@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> LJ U Was maintenance performed as required by septic system rules and the manufacturer? <br /> ▪ ❑ 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 /> ❑ ® Discharge of sewage to the ground surface? <br /> El • Discharge of sewage to drain tiles or surface waters? <br /> ❑ I] 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 *Certification Expiration: 5/20/2028 <br /> ('This line only can be filled out and photocopied.) p�p�• <br /> /(y(� <br /> Original Signature: I 1 ', Date: 1 Z/31/ZO25 <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 /> OF()Annual Oneration and Ma.ntenarm Reomt Form Hev 6,2022 <br />