Septage Pump Report Form - Hamilton County Public Health

Septage Pumping Report Form

The information contained in this report reflects the observations recorded at the time the system was pumped and includes any actions completed by the registered septage hauler. This report shall not be construed as a declaration of approval or disapproval or the proper function of the system.

Service Provider ID*
This was provided to you at your registration.
Driver/Technician Name*
Company Phone Number
Company Email
List the email you would like a copy of the pump report sent to.
Septage Hauling Company:
Registration Number:
Septage Pumping Information
Pumping Date*
Date Format: MM slash DD slash YYYY
Pumping Location Address*
Street Address Address Line 2 City ZIP / Postal Code
Name of person making the request for service*
Is this person the owner?*
- Yes
- No
Requester Phone Number*
Tank Pumping Information
- Residential
- Commercial
Total Gallons Pumped*
Disposal Location:*
- Waste Water Treatment Facility
- Land Application
Name of Treatment Facility*
Treatment Facility Permit Number*
Treatment Facility Address*
Number of Tanks*
- 1 Tank
- 2 Tanks
- 3 Tanks
- 4 Tanks
List all Repairs, Additional Work and Comments:
Tank 1
Volume Pumped
Tank Type*
- Septic
- Aeration
- Holding
- Dosing
- Privy Vault
- Portable Tank
- Other
If you selected "Other," please enter type
What type Aeration tank?
Was the aerator motor:
- Present
- Missing
Tank Material*
- Concrete
- Fiberglass
- Plastic
- Brick
- Metal
Tank Condition*
- Good
- Poor
- Could not determine
Evidence of Leaking*
- Yes
- Inconclusive
Indications that there are components of the tank leaking.
at the (check all that apply)
- Tank
- Riser
- Inlet
- Outlet
- Inconclusive
High Water Level at time of pumping?*
- Yes
- No
- Could not be determined
Evidence of previous tank high water level observed*
- Yes
- Inconclusive
Riser(s)*
- Present
- Absent
Riser(s) are located over
- Inlet
- Center of Tank
- Outlet
Inlet Riser Lid
- Present
- Absent
Inlet Riser lid condition:
- Good
- Poor
Center of Tank Riser Lid
- Present
- Absent
Center of Tank Riser lid condition:
- Good
- Poor
Outlet Riser Lid
- Present
- Absent
Outlet Riser lid condition:
- Good
- Poor
Baffle or Tee*
- Present
- Absent
- Not observed
Baffle or Tee Condition
- Good
- Poor
Effluent Filter*
- Present
- Missing
- N/A, tank older than 2007
Were they cleaned?
- Yes
- No
Other Solids Removed - Type of Material
- Filter Media
- Peat
- Other
- N/A
If other, name type.
Was dewatering necessary?*
- Yes
- No
- N/A
How many gallons?
Solid Waste Facility taken to
Did spillage occur during pumping process?*
- Yes
- No
Was area properly cleaned and disinfected?
- Yes
- No
Tank 2
Volume Pumped
Tank Type
- Septic
- Aeration
- Holding
- Dosing
- Privy Vault
- Portable Tank
- Other
If you selected "Other," please enter type
What type Aeration tank?
Was the aerator motor:
- Present
- Missing
Tank Material
- Concrete
- Fiberglass
- Plastic
- Brick
- Metal
Tank Condition
- Good
- Poor
- Could not determine
Evidence of Leaking?
- Yes
- Inconclusive
Indications that there are components of the tank leaking.
at the (check all that apply)
- Tank
- Riser
- Inlet
- Outlet
- Inconclusive
High Water Level at time of pumping?
- Yes
- No
- Could not be determined
Evidence of previous tank high water level observed
- Yes
- Inconclusive
Riser(s)
- Present
- Absent
Riser(s) are located over
- Inlet
- Center of Tank
- Outlet
Inlet Riser Lid
- Present
- Absent
Inlet Riser lid condition:
- Good
- Poor
Center of Tank Riser Lid
- Present
- Absent
Center of Tank Riser lid condition:
- Good
- Poor
Outlet Riser Lid
- Present
- Absent
Outlet Riser lid condition:
- Good
- Poor
Baffle or Tee
- Present
- Absent
- Not observed
Baffle or Tee Condition
- Good
- Poor
Effluent Filter
- Present
- Missing
- N/A, tank older than 2007
Were they cleaned?
- Yes
- No
Other Solids Removed - Type of Material
- Filter Media
- Peat
- Other
- N/A
If other, name type.
Was dewatering necessary?
- Yes
- No
- N/A
How many gallons?
Solid Waste Facility taken to
Did spillage occur during pumping process?
- Yes
- No
Was the area properly cleaned and disinfected?
- Yes
- No
Tank 3
Volume Pumped
Tank Type
- Septic
- Aeration
- Holding
- Dosing
- Privy Vault
- Portable Tank
- Other
If you selected "Other," please enter type
What type Aeration tank?
Was the aerator motor:
- Present
- Missing
Tank Material
- Concrete
- Fiberglass
- Plastic
- Brick
- Metal
Tank Condition
- Good
- Poor
- Could not determine
Evidence of Leaking?
- Yes
- Inconclusive
at the (check all that apply)
- Tank
- Riser
- Inlet
- Outlet
- Inconclusive
High Water Level at time of pumping?
- Yes
- No
- Could not be determined
Evidence of previous tank high water level observed
- Yes
- Inconclusive
Riser
- Present
- Absent
Riser(s) are located over
- Inlet
- Center of Tank
- Outlet
Inlet Riser Lid
- Present
- Absent
Inlet Riser lid condition:
- Good
- Poor
Center of Tank Riser Lid
- Present
- Absent
Center of Tank Riser lid condition:
- Good
- Poor
Outlet Riser Lid
- Present
- Absent
Outlet Riser lid condition:
- Good
- Poor
Baffle and Tee
- Present
- Absent
- Not observed
Baffle or Tee Condition
- Good
- Poor
Effluent Filters
- Present
- Missing
- N/A, tank older than 2007
Were they cleaned?
- Yes
- No
Other Solids Removed - Type of Material
- Filter Media
- Peat
- Other
- N/A
If other, name type.
Was dewatering necessary?
- Yes
- No
- N/A
How many gallons?
Solid Waste Facility taken to
Did spillage occur during pumping process?
- Yes
- No
Was the area properly cleaned and disinfected?
- Yes
- No
Tank 4
Volume Pumped
Tank Type
- Septic
- Aeration
- Holding
- Dosing
- Privy Vault
- Portable Tank
- Other
If you selected "Other," please enter type
What type Aeration tank?
Was the aerator motor:
- Present
- Missing
Tank Material
- Concrete
- Fiberglass
- Plastic
- Brick
- Metal
Tank Condition
- Good
- Poor
- Could not determine
Evidence of Leaking?
- Yes
- Inconclusive
Indications that there are components of the tank leaking.
at the (check all that apply)
- Tank
- Riser
- Inlet
- Outlet
- Inconclusive
High Water Level at time of pumping?
- Yes
- No
- Could not be determined
Evidence of previous tank high water level observed
- Yes
- Inconclusive
Riser
- Present
- Absent
Riser(s) are located over
- Inlet
- Center of Tank
- Outlet
Inlet Riser Lid
- Present
- Absent
Inlet Riser lid condition:
- Good
- Poor
Center of Tank Riser Lid
- Present
- Absent
Center of Tank Riser lid condition:
- Good
- Poor
Outlet Riser Lid
- Present
- Absent
Outlet Riser lid condition:
- Good
- Poor
Baffle and Tee
- Present
- Absent
- Not observed
Baffle or Tee Condition
- Good
- Poor
Effluent Filters
- Present
- Missing
- N/A, tank older than 2007
Were they cleaned?
- Yes
- No
Other Solids Removed - Type of Material
- Filter Media
- Peat
- Other
- N/A
If other, name type.
Was dewatering necessary?
- Yes
- No
- N/A
How many gallons?
Solid Waste Facility taken to
Did spillage occur during pumping process?
- Yes
- No
Was the area properly cleaned and disinfected?
- Yes
- No
Tank Service Recommended in:
Years
Months
Regular maintenance is necessary to prolong the useful life of your sewage treatment system.
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Septage Pumping Report Form

Septage Pumping Information

Tank 1

Tank 2

Tank 3

Tank 4

Tank Service Recommended in: