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State of Oregon Department of Environmental Quality /7&0•Wg"/i VfL <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: JONAH & JESSICA HANSON Phone: 503-999-2902 <br /> Site Address: 12038 HOLLY LN. Parcel#: 093W14D000800 <br /> City: JEFFERSON county Marion <br /> Permit it: Start 1Start up date if 1st year in use: /20/2016 <br /> System Model it, AX2ORT System serial#. 136266 <br /> Report Year: 2025 Date of Service Performed: 11/10/2025 <br /> Email Address: JESSHANSONRN@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 /> a ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> Q 0 Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ ❑a Is the system failing? <br /> ❑ E. Discharge of sewage to the ground surface? <br /> ❑ ID 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): Cory Morgan - A & B Septic Service <br /> 'Certification#: M 587 `Certification Expiration: 3/28/2026 <br /> ('This line only can be fill out and photocopied.) <br /> Original Signature ha, Date: 12/31/2025 <br /> Note: Maintenance provid t maintain accurate ecords of their maintenance contracts, customers, <br /> performance data,and timelines for r the co racts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DEO ANILI&Operation and 1 n-teran .R_pod i orm Rev 6,2022 <br />