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State of Oregon Department of Environmental Quality WSZ—/ " '\ <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: VERL L HOLDEN Phone: 503-881-0254 <br /> 8275 HAZEL GREEN RD 062W3500100 <br /> Site Address: Parcel#: <br /> City: SILVERTON County: Marion <br /> Permit#: 09-01877 Start up date if 1st year in use: NA <br /> System Model#: DELTA WW DF 50-FF System Serial#: <br /> N5-24113-FF <br /> Report Year: 2025 Date of Service Performed: 9/16/2025 <br /> Email Address: holdenwhoiesaleU@frontler.Cool <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> I ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> Q ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> l ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ❑� Is the system failing? <br /> ❑ • Discharge of sewage to the ground surface? <br /> ❑ Q 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 'fication Expiration: 5/20/2028 <br /> ('This line only can be filled out and photocopied.) ' <br /> '/n1VI 12/31/2025 <br /> Original Signature: ' 1 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 Operatics and Vaintenance Report Farm Rev.92022 <br />