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State of Oregon Department of Environmental Quality <br /> /7-0 M2 — /Nk <br /> SAAnnual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: LINDA L. DALLWIG Phone: 503-580-4034 <br /> 6652 COTTONWOOD ST. NE 072W22C0501 <br /> Site Address: Parcel#: <br /> city: SALEM County: Marion <br /> 08-02441 <br /> Permit#: Start up date if 1st year in use: NA <br /> System Model#: AX20-1 B System Serial#: 111316 <br /> Report 2025 8/12/2025 <br /> P Date of Service Performed: <br /> Email Address: RON@DALLWIGBROTHERS.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> a 0 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 /> [] ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ❑� Is the system failing? <br /> ❑ NI Discharge of sewage to the ground surface? <br /> ❑ MI Discharge of sewage to drain tiles or surface waters? <br /> ❑ it 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 'Certification Expiration: 5/20/2028 <br /> (*This line only can be filled out and photocopied.) j <br /> Original Signature: jtf �' / 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 operation and Maintenance Report Form Rev.6I2022 <br />