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State of Oregon Department of Environmental Quality M-" 0 Ott <br /> Annual Operation and Maintenance <br /> DEQ <br /> Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: JAMES BAKER Phone: 971-239-1490 <br /> 8143 SE MILL CREEK 082W26D 03300 <br /> Site Address: Parcel it: <br /> City' AUMSVILLE County: Marion <br /> Permit#: 555-05-05633 Start up date if 1st year in use: NA <br /> System Model#: AX2ON System Serial#: 105511 <br /> Report Year: 2025 Date of Service Performed: 12/15/2025 <br /> Email Address: hdjkb127@gmail.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> ❑ ❑ 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 /> I] ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ Q Is the system failing? <br /> ❑ I] Discharge of sewage to the ground surface? <br /> ❑ 17 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 r 'Certi ca�-�ion Expiration: 5/20/2028 <br /> ('This line only can be filled out and photocopied.) I if�{�rl � "'i, <br /> Original Signature. (/ 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 /> DEO knetki, Ivretia 1..1 iritendi re,Repo _rm key g.2pp <br />