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I�-0oo737- 1 Ng. <br /> State of Oregon Department of Environmental Quality <br /> SAI Annual Operation and Maintenance <br /> wit <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: JOSH BOATNER Phone: 503-949-0699 <br /> 15335 QUALL RD. NE 071 W01A02400 <br /> Site Address: Parcel#.• <br /> city: SILVERTON County: Marion <br /> 555-14-003138 8/21/14 <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: AX2ORT System Serial#: 128550 <br /> Report Year: 2025 Date of Service Performed: 9/5/2025 <br /> Email Address: outdoortrio@yahoo.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 /> El ❑ 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 /> ❑ Q Is the system failing? <br /> ❑ ❑� Discharge of sewage to the ground surface? <br /> ❑ IS Discharge of sewage to drain tiles or surface waters? <br /> ❑ 0 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 'Certi cation Expiration: 5/20/2028 <br /> ('This line only can be filled out and photocopied.) <br /> Original Signature: NIcf 7' 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 /> DEO Annual Opeabon and Maintenance Renon FoaA <br /> Rev o:zazz <br />