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3336 Sibley Memorial Hwy - Septic Maintenance Form 2012-06-07Jul 06 12 10:32a City of Date Pumped: Site Address: Owner's Name: Owner's Address (if different from site): Maintainer's Name: Private Residence: \C.! Commercial: Condition of Baffles: Pumped Through: Comments: Greg Gudbjartsson 952- 469 -3963 3830 Pilot Knob Road Eagan MN 55122 Phone: (651) 675 -5675 Fax: (651) 675 -5694 Email: commdevelopment Acityofeagan.com SEPTIC SYSTEM MAINTENANCE FORM - 17- # of Tanks Pumped: 3 75 /hit liktxeL Disposal Location t...0 A For Office Use Date Received:1 Staff: P.5 1,2 Total Gallons Pumped: 1 Z3 License Number: i,u w 11 Type of Tanks: Size of Tanks: / Z- :> C' Effluent Sewage Discharge: Yes: No: Please submit completed forms to the Building Inspections Division via mail, fax or email.