Maricopa County, AZ

Company Name*

Address*

Email Address*

5. Date of Facility Construction (Copy form either Item 7A or 7B of the REPORT OF INSPECTION form)

Before January 1, 2001, or
On or after January 1, 2001 as authorized by ADEQ or its delegated county agency, Maricopa County

6. Facility Type (Refer to Item 7 of the REPORT OF INSPECTION form)

Conventional septic tank/disposal system (very common—any system consisting of a septic tank that disposes effluent to trench, bed, chamber technology, or seepage pit), or
Alternative on-site system (not common—any system using an alternative technology for treatment or disposal)

7. Inspection Information (Copy all required information from the REPORT OF INSPECTION form)

Please indicate any file number/dates as indicated in Item 5 of REPORT OF INSPECTION form:

Discharge Authorization issued on or after January 1, 2001 (Item 5A of REPORT OF INSPECTION form):
Approval of Construction or other permitting document issued by ADEQ or Maricopa County before January 1, 2001 (Item 5B or REPORT OF INSPECTION form):

Please indicate the number of septic tanks in use on this property:

Was the septic tank(s) pumped as part of inspection (Item 8A of REPORT OF INSPECTION form)?

If the answer is No above, please indicate why the septic tank(s) were not pumped:

The septic tank was put into service less than 12 months before inspection, or
Pumping or servicing was not necessary at the time of inspection based on manufacturers written operation and maintenance instructions (applicable only to alternative technologies), or
No accumulation of floating or settled waste was present in the septic tank (may be applicable to certain remote or seasonal systems with little use).

Were repairs made as part of the inspection (Item 8Q of REPORT OF INSPECTION form)?

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