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�25 D6/92Q- //Y/ <br /> 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 NICK LARIONOR Phone: 503-951-9111 <br /> 19702 OLMSTEAD RD. NE. 041 W19 00500 <br /> Site Address: Parcel#: <br /> City: HUBBARD county: Marion <br /> 555-21-004150-PRMT 6/16/21 <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: SINGULAIR System Serial#: NA <br /> Report Year: 2025 Date of Service Performed: 10/28/2025 <br /> Email Address: fllcl(@Jaylahomes.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 /> Q ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> Q E Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ l9 Is the system failing? <br /> ❑ It Discharge of sewage to the ground surface? <br /> ❑ It Discharge of sewage to drain tiles or surface waters? <br /> E Q 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 Cepifi ti E 5/20/2028 <br /> ruhl piration: <br /> ('This line only can be filled out and photocopied) <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 /> DLL)Annual() er:lion and MantenanG.,l- por l min Pc-'v 62022 <br />