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I"1-rrmr-fl5O-I <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> `EQ DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: MIKE CARPENTER Phone: 503-310-4531 <br /> Site Address: 16913 SILVER OAKS LN. Parcel#. 061E29A02300 <br /> City: SILVERTON count,: Marion <br /> 555-15-000315 Start up date if 1st Y ear in use: 8/26/2015 <br /> Permit#: <br /> System Model#: AX2ORT System Serial#: 131024 <br /> Report Year: 2025 Date of Service Performed: 8/29/2025 <br /> Email Address: mikecafh@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> xn -❑ -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 /> ❑ I. Is the system failing? <br /> ❑ Q Discharge of sewage to the ground surface? <br /> ❑ ® Discharge of sewage to drain tiles or surface waters? <br /> ❑ Q 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 er{ificatio{ E 'ration: 5/20/2028 <br /> (*This line only can be filled out and photocopied.) - <br /> �Il 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 /> DEO Annual O eratInn a id t ai-, e nance Report Form Rev i2022 <br />