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HENNES SEPTIC PUMPING, LLC john@hennesseptic.com <br />Individual Sewage Treatment System (ISTS) Pumping Record {� 952-403-0058 <br />Owner k� Rti �WW. WV Address 7 N Y' ��t1i^� /Ll <br />PumperNo. of Tanks Pumped Total Gallons Pumped <br />Check all that apply AResidential ❑ Commercial Mental <br />--Septic ❑ Holding Pump Chamber ❑ Cesspool ❑ Abandoned ❑ Other: <br />Condition of Baffles (baffles must be inspected) XAcceptable ❑Unacceptable ❑Replaced Baffles <br />Reason for pumping.? Water tight tank? Alves ❑ No <br />Disposal Location (be specific) <br />Any tank leakage below or above the operating depth? -❑ Yes f, No <br />Pumped From: XMaintenance Hole ❑ Removed Tank Lid (stave, for example) ❑ Inspection Pipe (see below) <br />I have been informed about the correct tank cleaning procedures and understand that I risk having my system fail prematurely if the tank is not <br />pumped through the Maintenance Hole / Tank Lid to enable the removal of solids. <br />Signature of Owner / Owner's Agent Reason for not pumping through the Maintenance Hole / Tank Lid <br />Safety Concerns / Repairs <br />Pumper/ Inspector Signature �� Dater <br />Only one permit is needed per ISTS. If there is more than one ISTS on a property, submit a separate permit for each ISTS. Submit a:permit whenever <br />a tank is pumped for abandonment. Pumping the tank does not constitute a compliance inspection. <br />