4155 South Robert Tr - Septic Maintenance Form 2017-05-09 Ju1. 06.2017 04 :48 PM Valley Elacktopping, Inc. 6514523220 PAGE. 5/ 6
For Office Use
I I
Date Received: Z I
City of EaEd� Staff: _ 1
3630 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675 RECEIVED
Fax; (651) 675-5694
Email: commdevelopment(a)cityofeagan.com 101.. 0 6 2017
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: 2 0) of Tanks Pumped: Total Gallons Pumped:
0
Site Address: X
Owner's Name; 1.(,Loa /� Sfx%�?.q q�—` �/✓�
Owner's Address (if different from site): n n
'S S e f l
License Number:Maintainer's Name:
Private Residence: Commerclal: / _ Disposal Location:&- e�kL", �y 31.114) ,e
Condition of Baffles: i l''� '°�- Type of Tanks: a Size of Tanks: .2 '
Pumped Through: Effluent Sewage Dlscharge; Yes: No:k4
Comments:
Please submit completed forms to the Building Inspections Division via mail,fax or email.
Ju1. 06. 2017 04 : 45 PM Valley Blacktopping, Inc. 6514523220 PAGE. 6/ 6
LIKE us on Facebook: Terms Due Date P.O, No. "`VISA&Mastercard Accepted
LaRoche's Sewer,Drain A processing fee of 2%Neill be added
&Septic Services Nei 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 disposal at the Empire Waste Treatment Plant:
Balance Due 53$5.00
Thank You — Your Business is Valued and Appreciated!
LIkP us on Faeebook Late fees will be added to all past due accounts.
LaTio6he'y Sewer,Drain& 3Pprin SArvie.ra Visa& Mastercard aceecpted.