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.� - State of Oregon Department of Environmental Quality .25-x541- Al" <br /> Annual Operation and Maintenance <br /> DEQ <br /> Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: MIKE HANSON Phone: 503-710-0089 <br /> 11410 FARGO RD NE Parcel#: <br /> 041W090000300 <br /> Site Address: <br /> City. AURORA County: Marion <br /> Permit#: 555-23-008911-PRMT Start up date if 1st year in use: 10/24(2024 <br /> System Model#: AX2ORT System Serial#. 200729 <br /> Report Year: 2025 Date of Service Performed: 10/28/2025 <br /> Email Address: SCHIEDELNURSERY@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 /> l] ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> *❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ II Is the system failing? <br /> ❑ El Discharge of sewage to the ground surface? <br /> ❑ I] 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#: M 711 *Certification Expiration: 5/20/2028 <br /> ("This line only can be filled out and photocopied)Original Signature: I" <br /> NL A IX'AV Date: 12/31/2025 <br /> _ <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 /> DE:Annual Operation ar0 Ma nteriance Report Form key 6:2022 <br />