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State of Oregon Department of Environmental Quality /7 laV 79 /A/U{ <br /> SA Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: GRANT HARTENSTEIN Phone: 503-678-4567 <br /> s Address: 9625 IDA LN. Parcel#: 041W19B01800 <br /> city: AURORA county: Marion <br /> Permit#: 07-01751 Start up date if 1st year in use: NA <br /> System Model#: DELTA WW DF 50-FF System Serial#: <br /> NA <br /> Report Year: 2025 Date of Service Performed: 11/3/2025 <br /> Email Address: ghartenstein@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> a- ❑- was maintenance performed as required by septic system rules and the manufacturer? <br /> i ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> *❑ El Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ it Is the system failing? <br /> ❑ 1. Discharge of sewage to the ground surface? <br /> ❑ 0 Discharge of sewage to drain tiles or surface waters? <br /> ❑ IN Sewage backup into plumbing fixtures? <br /> If you answered"Yes"on the last four questions,was a repair permit obtained? If not, explain: <br /> t 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 Certifi tin Expiration: 5/20/2028 <br /> ('This line only can be filled out and photocopied.) h <br /> � 12/31/2025 <br /> Date:Original Signature: <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 /> DEC ennual trperalpor emu M rete nce Report' nun Rev 6•2022 <br />