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(Supplemen=~l F~rm~ <br /> <br /> ~r~r to properlg evaluate ~our exis=ing s~wage system, the follc~ing <br />information will b~ <br /> <br /> ~ve ~ app~vo~ recold of ch~. s~stem, w~ can pro~d w~thou~ <br /> <br /> verif~ <br /> <br /> will no= be required. <br /> <br /> -For Se c"Ta~ Pum~r use Only- <br /> <br />C~PANY <br /> <br />LICENSE NO: <br /> <br />PROPERTY OW.%'~R:.. <br /> <br />ADDRESS WHERJ~ TANK PUMPED~. <br /> <br />91 61 Smith Rd. SE <br /> <br />A%m~ville, C~ <br /> <br />~allon$ Ooncrete <br /> <br />34916 <br /> <br />IS T~¥K IN GOOD COUDIT~ON? <br /> <br />XX YES; NO <br /> <br />ARS BAFFLES OR ~2BOWS IN P~.~CE? <br /> <br />XX YES; NO <br /> <br />IS DPw%INFI~LD BACKING UP INTO <br /> <br />__YES; XX NO <br /> <br />If yes. exr. lain~ <br /> <br />DZAGP~A~I OF <br />LOCATI~¥ OF <br /> <br />~X~tprJ~: <br /> <br />6'~ Se9=ic Tank <br /> <br /> <br />