Adeq Report Of Inspection Of An On-Site Wastewater Treatment Facility Page 2
ADVERTISEMENT
1
2
3
4
5
6
7
8REPORT OF INSPECTION
-
OF AN ON
SITE WASTEWATER
TREATMENT FACILITY
1
P
I
(All fields are required)
ROPERTY
NFORMATION
Address
County
Tax Parcel No.
City
Zip
Residential property
Non-residential property
2
C
O
I
(All fields are required)
URRENT
WNER
NFORMATION
Name
Mailing Address
City
State
Zip
3
I
I
(All fields are required)
NSPECTOR
NFORMATION
Inspector Name
NAWT Inspector No.
Company Name
Address
Phone No.
Fax
Email
4
I
Q
(Inspectors must fill out Section A, and check at least one box in Section B)
NSPECTOR
UALIFICATIONS
A. Coursework requirement
Name of ADEQ-approved Course:
City where Course was taken
Date Completed:
Registration/
Expiration
B. License/Registration (check at least one box)
License No.
Date
Owner of a vehicle with a Human Excreta Collection and Transportation
License (a Septage Hauler license), issued pursuant to A.A.C. R18-13-1103.
Check one:
Owner of license;
Employee of licensed owner
Wastewater Treatment Plant Operator licensed pursuant to A.A.C. R18-5
-101 through 116 (indicate type):
Grade 1;
Grade 2;
Grade 3;
Grade 4
Arizona Registered Sanitarian
Arizona Professional Engineer
Licensed Contractor (indicate type):
Residential B-4 or C-41;
Commercial A, A-12, or L-41; or
Dual KA or K-41
A person qualifying under another category designated by the Department (describe)
5
D
C
(Answer as applicable)
OCUMENTS
ONSULTED
Were facility permit, construction and/or operational records available?
No
Yes (indicate below)
A)
Yes
No Discharge Authorization (or Verification) issued on or after January 1, 2001 pursuant to
R18-9-A301(D)(2)(c). If yes, indicate agency File No: __________ and date issued
B)
Yes
No Approval of Construction issued by ADEQ or its delegated County agency before January 1,
2001. If yes, indicate agency File No. __________ and date issued ___________________
C)
Yes
No Site plan, plot plan, “as-built” drawings, or similar documents (describe): _____________
D)
Yes
No Documents relating to operation and maintenance (alternative systems)
E)
Yes
No Other (describe): ________________________________________________________
F
GWS 432 (R
,
16, 2007)
P
1
7
ORM
EVISED
FEBRUARY
AGE
OF
DOWNLOAD THE LATEST UPDATE OF THIS FORM FROM THE ADEQ WEBSITE AT
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form En-651-010 - Application For On-site Wastewater Treatment System Designer Practice Permit
Legal
Report Of Employer On Termination Of Registration Form - Division Of Taxation - Rhode Island
Financial
Related Categories
Parent category: Business