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State of Oregon Department of Environmental Quality 020 `r' "I/"4C)/ <br /> SiE Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: LORI KIMBALL 503-930-3158 <br /> Phone: <br /> Site Address: 12583 BRICK RD. SE. 092W24CO200 <br /> Parcel#. <br /> City: TURNER Marion <br /> county: <br /> Permit it: 555-18-006992 7/26/19 <br /> Start up date if 1st year in use: <br /> AX2ORT 139888 System Model x: <br /> System Serial#: <br /> Report Year: 2025 11/17/2025 <br /> P Date of Service Performed: <br /> Email Address: lorabell@wvi.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 /> x❑ ❑ 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 /> ❑ ❑� Is the system failing? <br /> ❑ ❑� Discharge of sewage to the ground surface? <br /> ❑ IN Discharge of sewage to drain tiles or surface waters? <br /> ❑ ® 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 'Certification Expiration: 5/20/2028 <br /> (*This line only can be filled out and photocopied.) /r,, }ry'1 <br /> Original Signature: I"'` Date: 1 Z/31/ZOZS <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 Annual Operal Dn and Maintenance Repo:l Four <br /> Pea ii2022 <br />