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July 2019
Facility Type (Refer to Item 7 of the REPORT OF INSPECTION form)
Conventional septic tank/disposal system (very common—any system consisting of a septic tank that disposes effluent
to trench, bed, chamber technology, or seepage pit), or
Alternative on-site system (not common—any system using an alternative technology for treatment or disposal)
Inspection Information (Copy all required information from the REPORT OF INSPECTION form)
Date of Inspection (from Item 13 of Report of Inspection form):
Design flow of facility (from Item 6E of Report of Inspection form):
Please indicate any file number/dates as indicated in Item 5 of Report of Inspection form:
Discharge Authorization issued on or after January 1, 2001 (Item 5A of Report of Inspection form):
File No. ________________ Date issued: __________________, or
Approval of Construction or other permitting document issued by ADEQ or Maricopa County before January
1, 2001
(Item 5B of Report of Inspection form): File No. _______________ Date issued: ____________________
Please indicate the number of septic tanks in use on this property:
Was the Septic tank(s) pumped as part of inspection (Item 8A of Report of Inspection form)? Yes No
If the answer is No above, please indicate why the septic tank(s) were not pumped:
The septic tank was put into service less than 12 months before inspection, or
Pumping or servicing was not necessary at the time of inspection based on manufacturers written operation and
maintenance instructions (applicable only to alternative technologies), or
No accumulation of floating or settled waste was present in the septic tank (may be applicable to certain remote or
seasonal systems with little use).
Were repairs made as part of the inspection (Item 8Q of Report of Inspection form)? Yes No
Form Submittal and Buyer/Transferee Advisory (All information is required)
Date of property transfer (closing date):
Date of submittal of this Notice of Transfer form:
Check this box to confirm the $50 filing fee is being submitted with this Notice of Transfer form
Please Select who is submitting this Notice of Transfer Form:
A person submitting this form on behalf of the Buyer/Transferee (Please complete the required information below)
Relationship of submitter :
Escrow Officer/Title Company, or Other (indicate):
_____________________
Certification/Signature (All information is required)
I, as the Buyer/Transferee, certify that I have received a Report of Inspection from the Seller/Transferor or their
representative, and that I have accurately completed this Notice of Transfer form to the best of my knowledge, or
I, as a person submitting this form on behalf of the Buyer/Transferee, certify that the information provided in this Notice of
Transfer form is complete and accurate to the best of my knowledge.
Signature:_____________________________________________
File Number:__________________________
If you file your Notice of Transfer by email, once processed by the Department, you will receive an email with instructions and
options for payment of the Notice of Transfer $50 filing fee. The Notice of Transfer will be complete once payment has been made.
Checks must be made payable to Maricopa County Environmental Services Department (M.C.E.S.D.).
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