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-erg State of Oregon Department of Environmental Quality /7-(/00c I/-/Ni <br /> Annual Operation and Maintenance CC <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: DAN ELLIS Phone: 503-320-6584 <br /> 23955 BUTTEVILLE RD NE 031 W32CA00400 <br /> Site Address: Parcel it <br /> City: AURORA Marion <br /> County: <br /> 555-10-03107 8/3/11 <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: AX2ON System Serial#: 122777 <br /> Report Year: 2025 Date of Service Performed: 12/22/2025 <br /> Email Address: DANELLIS2022@GMAIL.COM <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> I] ❑ 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 /> x❑ El Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ El Is the system failing? <br /> El I Discharge of sewage to the ground surface? <br /> ❑ I Discharge of sewage to drain tiles or surface waters? <br /> ❑ It 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 it: M 711 *Certification Expiration: 5/20/2028 <br /> (*This line only can be filled out and photocopied.) 1 <br /> Original Signature: Nir^` / Date: 12/31/2025 <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 /> DEQ Annual Operation and Maintenance Report I orm Rev.6/2022 <br />