Septage Pump Report Form - Hamilton County Public Health

Septage Pumping Report Form

Service Provider ID*

This was provided to you at your registration.
Driver/Technician Name*
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Company Phone Number
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Company Email

List the email you would like a copy of the pump report sent to.
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Septage Hauling Company:
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Registration Number:
Septage Pumping Information
Pumping Date*
MM slash DD slash YYYY
Pumping Location Address*
Street Address Address Line 2 City ZIP 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: