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Ii— COO 751 - Al(Q <br /> _.e Q. State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL Information) <br /> Property Owner: DARLENE CARTER Phone: 503-871-5540 <br /> Site Address: 680 DOE LN. NE Parcel#: 061W34BA01900 <br /> City' SILVERTON County: Marion <br /> Permit#: 11-03396 Start up date if 1st year in use: 2/27/12 <br /> SINGULAIR 900146MZ <br /> System Model#: System Serial*: <br /> Report Year: 2025 Date of Service Performed: 9/16/2025 <br /> Email Address: decarter3@yahoo.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> x❑ ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> a ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> I] ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ I] Is the system failing? <br /> ❑ ® 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 •Certi a 'on Expiration: 5/20/2028 <br /> ("This line only can be filled out and photocopied.) r� <br /> Original Signature: <br /> l Date: 12/31/2025 <br /> Note: Maintenance providers must maintain accurate records of their maintenance contracts, customers, <br /> performance data,and timelines far renewing the contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> OEQ Anrpa Operation and Marntena n cc Report Form Rev 5,2022 <br />