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— <br /> State of Oregon Department of Environmental Quality 0//50 / )/ <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: <br /> MATTHEW GRIFFITH Phone: 503-798-1862 <br /> s e Address: 10177 STAYTON RD SE Parcel#: 091 W 18D00700 <br /> City. AUMSVILLE County: Marion <br /> 555-23-004764 Start u date if 1st year in use: 09/01/2023 <br /> Permit It p <br /> System Model#: 20N System Serial#: MVP <br /> Report Year: <br /> 2025 Date of Service Performed: 8/13/2025 <br /> Email Address: OUTDOORSMEN22@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 /> _❑ ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> Q ❑ 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 /> ❑ ® Discharge of sewage to drain tiles or surface waters? <br /> ❑ • 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 ification Expiration: 5/20/2028 <br /> (•This line only can be filled out and photocopied.) qq <br /> 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 /> pEQ Anneal Operation and Ma I tnnanne Repo[;Rim Rev o2C22 <br />