4135 South Robert Tr - Septic Maintenance Form 2017-05-09 Ju1. 06.2017 04 :47 PM Valley Blacktopping, Inc. 6514523220 PAGE. 2/ 6
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For Office Usa
I I
I Data Received:,
City of Ea a� I
I Staff: _
3630 Pilot Knob Road
Eagan Mtn 55122
Phone: (651) 676.5675
Fax: (651)675-5694 R E �
C a
Email: commdevelopment ltyofea-gan.com .€
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JLII. 0 6 2017
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped; / p f #of Tanks Pumped: Total Gallons Pumped: Sev t",
Site Address:
Owner's Name: C��.1.� �! �c �.�? _• /�- �i,/t , �1�
Owner's Address (If different from site):
Maintainer's Name: Lo, V0 dde S License Number:
Private Residence: Commercial: Disposal Location: eyy%it tt� W W T
Condition of Baffles: 471 Type of Tanks:l JCS' eA A I Slze of Tanks:
Pumped Through: Effluent Sewage Discharge: Yes: No:
Comments: a ��" ,.�1 Q.2-- �- �,.0 JJL Cj l -ct•.�c- _....
Please submit completed fortes to the Building Inspections Division via mall,fax or email.
Ju1. 06.2017 04:47 PM Valley Blacktopping, Inc. 6514523220 PAGE. 3/ 6
LIKE us on Facebook; Terms Due Date P.O, No. "wV1SA&Mastercard Accepted
LaRoche`s Sewer,Drain A processing fce of 2%«•i11 be addcd
&Septic Services Nct 15 6/2/2017 to the transaction.
Serviced Description Amount
5/9/2017 Pumping of the shop septic tank and the two tanks at the Mini-Storage 385.00
Building-fee includes disposQ1 at the Empire Waste Treatment Plant:
Balance Due $385.00
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Late Fees will be added to all past due accounts.
I-aRoche's sewer,Drain&Septic Servicas Visa&Mastercard acceepted.