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I7 ooOfO)- RA <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ <br /> Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: PHILLIP CLARK Phone: 608-658-3937 <br /> Site Address: 3007 CASCADE HWY NE Parcel it 071W16000900 <br /> City: SILVERTON County: Marion <br /> Permit#. 555-15-007447-SEP Start up date if 1st year in use: NA <br /> SANDFILTER NA <br /> System Model#: System Serial#. <br /> Report Year: 2025 Date of Service Performed: 9/10/2025 <br /> Email Address: Phillipaclark@yahoo.com <br /> Onsite wastewater treatment system status: (Do not preftll and photocopy checkboxes) <br /> Yes No <br /> a ❑ 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 ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ 0 Is the system failing? <br /> ❑ El Discharge of sewage to the ground surface? <br /> ❑ ® Discharge of sewage to drain tiles or surface waters? <br /> ❑ II Sewage backup into plumbing fixtures? <br /> If you answered"Yes"on the last four questions,was a repair permit obtained? If not, explain: <br /> "-certify-that-thisreport 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 i Expiration: 5/20/2028 <br /> ('This line only can be filled out and photocopied.) <br /> Original Signature: _ Date: <br /> 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 /> OEo Apnea operation and rear aenarw Report Farr key.62022 <br />