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„erg, State of Oregon Department of Environmental Quality z DO//42 - /x &/ <br /> SAnnual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property Owner: SUSANNE WHITE-THORUD Phone: 503-884-2954 <br /> Site Address: 4772 DELANh' RD SE Parcel#: 082W29CA00200 <br /> City: TURNER County: Marion <br /> 555-22-005298 02/09/2023 <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: AX2ORT System Serial#: LOGO BOARD <br /> Report Year: 2025 Date of Service Performed: 8/13/2025 <br /> Email Address: SUZI@THORUDSONS.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 /> l ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ • Is the system failing? <br /> ❑ Q Discharge of sewage to the ground surface? <br /> ❑ ❑� Discharge of sewage to drain tiles or surface waters? <br /> ❑ U 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 "Certification Expiration: 5/20/2028 <br /> ('This line only can be filled out and photocopied.) <br /> Original Signature: N I 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 Annual Operation and Maintenance Report Form Rev 6.2022 <br />