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1436 Highview Ave - Septic Maintenance Form 2012-06-06Jul 06 12 10:31a Greg Gudbjartsson City of EaQall 3830 Pilot Knob Road Eagan MN 55122 Phone: (651) 675 -5675 Fax: (651) 675 -5694 Email: commdevelopment (c� citvofeagan.com Date Pumped: Site Address: Owner's Name: Condition of Baffles: Pumped Through: Comments: ILI:30 PO R741Rt-C° - t Owner's Address (If different from site): � C; Maintainer's Name: �� eiCL'-.C'1 Private Residence: Commercial: SEPTIC SYSTEM MAINTENANCE FORM # of Tanks Pumped: — Z__ Total Gallons Pumped: NL Disposal Location: Type of Tanks: 952- 469 -3963 e ;UC= For Office Use 1n Date Received: 11 a 1 1 ` Staff: e' , License Number: �` �� f ' ICJ c-P Size of Tanks: p.3 Effluent Sewage Discharge: Yes: No: Please submit completed forms to the Building Inspections Division via mail, fax or email.