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State of Oregon Department of Environmental Quality C > / ()&//5 —/v V <br /> Annual Operation and Maintenanceri <br /> 111 <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: JEREMIAH GOLDEN 503-989-9408 <br /> Phone: <br /> Site Address: 13663 MCKEE SCHOOL RD 051 W210003000 <br /> Parcel#: <br /> City: WOODBURN county: Marion <br /> Permit#: 555-21-002405 07/25/2023 <br /> Start up date if 1st year in use: <br /> AX2ORT 148565 System Model#: <br /> system Serial#: <br /> Report Year: 2025 10/2/2025 <br /> Date of Service Performed: <br /> Email Address: JSGOLDEN50@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> El ❑ 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 /> ❑ ❑� Is the system failing? <br /> ❑ HI Discharge of sewage to the ground surface? <br /> ❑ 0 Discharge of sewage to drain tiles or surface waters? <br /> ❑ I� 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 *Ceti c tion Expiration: 5/20/2028 <br /> (*This line only can be filled out and photocopietlJ n � <br /> Original signature: 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 /> DEC Annual Operation and Maintenance Report Form <br /> Rev Y2022 <br />