The third component will be an annual report generated by MDEQ that will be distributed to all local health departments. MDEQ annual report will summarize all local health department data submissions. Date: _____________ MDEQ Failed System Data Collection Form Non-Residential – Address: Township: _________________County: _________________ Facility Type: Church Dental/Medical Gas Station Grocery Store Industrial Multi-Family Office/Retail Restaurant School Other ______________________ <1,000 1,000 6,000 >6,001 10,000 >10,000 Estimated – – (gallons per day) Septic Tank Type: Single Two Compartment More Than One Tank No Tank Septic Tank Capacity Gallons: – <1,000 1,000 1,500 >1,500 2,000 >2,000 3,000 – – – >3,000 Unknown Advanced Treatment Unit Yes No If yes, Treatment Unit Name: System Design: Gravity Bed Dosed Bed Pressure Dosed Bed None Gravity Trenches Trenches Pressure Dosed Trenches Unable to Determine Gravity Dosed Mound Pressure Dosed Mound Chambers Drywells Other ________________________ System Age: 0 5 6 10 11 15 16 20 21 25 – – – – –
The third component will be an annual report generated by MDEQ that will be distributed to all local health departments. MDEQ annual report will summarize all local health department data submissions. Date: _____________ MDEQ Failed System Data Collection Form – Non-Residential Address: Township: _________________County: _________________ Facility Type: Church Dental/Medical Gas Station Grocery Store Industrial Multi-Family Office/Retail Restaurant School Other ______________________ Estimated <1,000 1,000 – 6,000 >6,001 – 10,000 >10,000 (gallons per day) Septic Tank Type: Single Two Compartment More Than One Tank No Tank Septic Tank Capacity – Gallons: <1,000 1,000 – 1,500 >1,500 – 2,000 >2,000 – 3,000 >3,000 Unknown Advanced Treatment Unit Yes No If yes, Treatment Unit Name: System Design: Gravity Bed Dosed Bed Pressure Dosed Bed None Gravity Trenches Trenches Pressure Dosed Trenches Unable to Determine Gravity Dosed Mound Pressure Dosed Mound Chambers Drywells Other ________________________ System Age: 0 – 5 6 – 10 11 – 15 16 – 20 21 – 25
Onsite-Wastewater-2017.docx