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State of Oregon Department of Environmental Quality G"O tbt/Lii 3-'I`)Q l <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> BRONEC TRUST 503-279-3164 <br /> Property Owner: Phone: <br /> 17621 FRONT ST. NE 041 W330000700 <br /> Site Address: Parcel#: <br /> HUBBARD MARION <br /> City: County: <br /> UNKNOWN 4/14/2025 <br /> Permit#: Start up date if 1st year in use: <br /> System Model#: AX2ORT System Serial#: 147021 <br /> Report Year: 2025 Date of Service Performe l: 10/28/2025 <br /> Email Address: hrobinson@columbiatrustcompany.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 /> El ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ I] 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 `Cert is tion Expiration: 5/20/202$ <br /> (*This line only can be filled out and photocopied.) <br /> Original Signature: I 1 I" Date: 1 Z/31/ZOZS <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 rPorilial Operation and Maintenance• coort I or.. eev &;zozz <br />