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State of Oregon Department of Environmental Quality 'if2—Vb a 1 -1)"k ` <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> C SC Vpal-a5 <br /> General Information (Complete ALL information) <br /> Property Owner: UULIANA IVANOV & EROS KUZMIN Phone: 503-310-7237 <br /> Site Address: 6790 CREEK LN. NE Parcel#: UNKNOWN <br /> City: SILVERTON County: MARION <br /> Permit#: UNKNOWN Start up date if 1st year in use: 8/29/25 <br /> System Model#: AX2ORT UV System Serial it: LOGO <br /> Report Year: 2025 Date of Service Performed: <br /> Email Address: KUZMINJULIE@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> Q ❑ 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 /> ❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ It Is the system failing? <br /> ❑ ® Discharge of sewage to the ground surface? <br /> ❑ Q 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 /> """' START-UP DONE AFTER 7/1/2025 <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 ft. M 711 'Certification Expiration: 5/20/2028 <br /> (*This line only can be filled out and photocopied.) <br /> Original Signature: NiL(( 5I 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 Opeiat on and Maintenance Report Fan-. :eV 02022 <br />