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/7 00975?- /it/c <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: Michael Corey Phone: 503-749-1273 <br /> Site Address: 8874 Robert Lane SE Parcel# 082W36C000302 <br /> City: <br /> Aumsville County: Marion <br /> Permit#: 08-01700 Start up date if 1st year in use: NA <br /> System Model#: AX20-1 B System Serial#: 114665 <br /> Report Year: 2025 Date of Service Performed: 12/15/2025 <br /> Email Address: michaelcorey6@aol.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 /> a ❑ 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 /> ❑ ❑� Is the system failing? <br /> ❑ ❑� Discharge of sewage to the ground surface? <br /> ❑ Discharge of sewage to drain tiles or surface waters? <br /> ❑ E. 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 rti cation Expiration: 5/20/2028 <br /> (This line only can be filled out and photocopied.) rI <br /> 12/31/2025 <br /> Original Signature: _ Date: <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 /> DLO al Oper:0100 ond Vainitma020 lkeport Foam Re. 2.2022 <br />