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J2- p009if I- l J1C <br /> State of Oregon Department of Environmental Quality <br /> 144 Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: PAUL STEWART Phone: 503-769-2441 <br /> Site Address: 11936 BELDEN DRIVE SE Parcel#: 555-07-02767 <br /> ci AUMSVILLE county: Marion <br /> ty <br /> 092W13 01200 Start up date if 1st year in use: NA <br /> Permit#: <br /> System Model#: AX2ON System Serial#: 113662 <br /> Report Year: 2025 Date of Service Performed: 12/15/2025 <br /> Email Address: pls42@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 /> El ❑� 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 /> ❑ Q Is the system failing? <br /> ❑ Q Discharge of sewage to the ground surface? <br /> ❑ 0 Discharge of sewage to drain tiles or surface waters? <br /> ❑ I] Sewage backup into plumbing fixtures? <br /> If you answered"Yes"on the last four questions,was a repair permit obtained? If not,explain: <br /> ***UV HAS FAILED, WORKING WITH ORENCO TO FIND A SOLUTIONF OR UV"" <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 ertification Expiration: 5/20/2028 <br /> (*This line only can be filled out and photocopied) <br /> Original Signature: Date: <br /> 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 /> Annual Operation P amtenantx Report Form Rev R2022 <br />