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State of Oregon Department of Environmental Quality <br /> / �Od77P-/N <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: JERROLD HIGGINBOTHAM Phone 503-348-2428 <br /> Site Address: 9653 HUB LANE NE Parcel#: R344192 <br /> City. AURORA County Marion <br /> Permit#: 555-14-002673 start up date if 1st year in use: 9/16/14 <br /> System Model u: AX2ORT 1 B System Serial a: 129129 <br /> Report Year: 2025 Date of Service Performed: 11/3/2025 <br /> Email Address: lakenancyhigg@yahoo.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> [] ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> _❑ ❑ 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 /> ❑ i] Is the system failing? <br /> ❑ in Discharge of sewage to the ground surface? <br /> ❑ IN Discharge of sewage to drain tiles or surface waters? <br /> ❑ 0 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 u: M 711 •Certi c lion Expiration: 5/20/2028 <br /> (*This line only can be filled out and photocopied.) <br /> Original Signature: IUl Date: 12/31/2025 <br /> 1 � <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 /> DE0 Annual operation and Mamtena nee Report:aim Rev 6,2022 <br />