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-e-r9 State of Oregon Department of Environmental Quality /7—00 792 / Q <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Propertyowner: TRAVIS & ELYSE HANSEN Phone: 503-803-1631 <br /> Site Address: 9694 IDA LANE NE Parcel#: 555-07-01756 <br /> city: AURORA County: Marion <br /> 041W19B 01701 <br /> Permit#: Start up date if 1st year in use: NA <br /> System Model#: AX2ORT System Serial#: 127867 <br /> Report Year: 2025 Date of Service Performed: 11/3/2025 <br /> Email Address: e.hansen@live.com <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> Yes No <br /> ❑ - 0 - Wasrnaintenance performed as required by septic system rules and the manufacturer? <br /> x❑ El Is the system operating in accordance with the agent-approved design specifications? <br /> ID ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> El I] Is the system failing? <br /> El • Discharge of sewage to the ground surface? <br /> ❑ II 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 ( 1 di cation Expiration: 5/20I2028 <br /> ('This line only can be filled out and photocopied.) /` i,.y�)v /, �ie (/ <br /> Original Signature: I1rl �I1 LY /`% 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 /> DEQ Annua Operation and A4aintena n ce kepor:i are Pet/ 6:2022 <br />