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610 Lone Oak Rd - Septic Maintenance Form 2012-04-19City of Evan Comments: 3830 Pilot Knob Road Eagan MN 55122 Phone: (651) 675 -5675 Fax: (651) 675 -5694 Email: commdevelopment acitvofeagan.com Owner's. Address (if different from site): RECEIVED MAY 31 2012 For Office Use Date Received: 5 Staff: SEPTIC SYSTEM MAINTENANCE FORM Date Pumped: f/ a04 # of Tanks Pumped: . Total Gallons Pumped: 9 op Site Address: � �d 1- O// OA AD 5,4 CIA(V) A4 /1/ ) Owner's Name: ©M 1 V/ l /cEi5 (/j NA i Maintainer's Name: r PT2C 1E/� v C � License Number: MOM /06- el Private Residence: Commercial: Disposal Location: Condition of Baffles: Type of Tanks: PL 4 S rr(, Size of Tanks: /006 64 L. Pumped Through: Effluent Sewage Discharge: Yes: No: AI .p 7" °'' 0 7/. T . L ? ivoivx 637- '3 7 /'/ O Please submit completed forms to the Building Inspections Division via mail, fax or email. [ ADDRESS fr" , b / t IONCE 0 4 IL AD IADDRE, CITY, STATE, ZIP 1 Crre, ST . (CUSTOMER ORDER NO. SOLD BY TERMS F.O.B. DATE ( 0 ), i SHIPPD D PRI CE NT 111.1=1116 V.4,0-S-LiTriL 1:7Zic-1.. 11 : .....,......._,.... mil oo') U'L.23 M A Y 3 1 2012 SHIP TO L 88d643 01,1