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State of Oregon Department of Environmental Quality 1 g- bt)\��� <br /> Annual Operation and Maintenance <br /> ;D.EQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: DARREN PALMER Phone: 503-754-5146 <br /> Site Address: 24485 NE BUTTEVILLE RD. Parcel#: 031W32A00400 <br /> City: AURORA County: MARION <br /> Permit#: 555-15-007304-SEP Start up date if 1st year in use: 6/1/2017 <br /> System Model#: AX2ON B1 System Serial#: 134751 <br /> Report Year: 2025 Date of Service Performed: 9/30/2025 <br /> Email Address: N/A <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 /> .❑ ❑ 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 /> ❑ E Discharge of sewage to drain tiles or surface waters? <br /> ❑ Q 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 certifylhatihis-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: <br /> 5/20/2028 <br /> (*This line only can be filled out and photocopied.) <br /> Original Signature: III 't / 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 /> DEC)Ann ?)per-!Jon and MaVen3nor Popon Dov.6 20%2 <br />