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Q State of Oregon Department of Environmental Quality I�'�O9 39 --(A) <br /> _erg <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Property owner: TONI RUEF phone: 503-845-2694 <br /> Site Address: 12265 W. CHURCH RD. Parcel it 061W090000300 <br /> city: MT. ANGEL County: Marion <br /> Permit#: 09-04774 Start up date if 1st year in use: UNKNOWN <br /> System Model#: DELTA WHITEWATER System serial#: 24681 <br /> Report Year: 2025 Date of Service Performed: 8/14/2025 <br /> Email Address: toni@mtangel.net <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> xLJ ❑ Was maintenance performed as required by septic system rules and the manufacturer? <br /> Q ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> ❑ ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ IN Is the system failing? <br /> ❑ In Discharge of sewage to the ground surface? <br /> ❑ ❑� Discharge of sewage to drain tiles or surface waters? <br /> ❑ ❑� 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 /> ('' <br /> Original Signature: IC; 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 Annual Operation and tlaimenanw Report l of Rev 62022 <br />