ADEQ Form GWS 432 Report of Inspection of an on-Site Wastewater Treatment Facility - Arizona

Form GWS432 is a Arizona Department of Environmental Quality form also known as the "Report Of Inspection Of An On-site Wastewater Treatment Facility". The latest edition of the form was released in February 16, 2007 and is available for digital filing.

Download a PDF version of the Form GWS432 down below or find it on Arizona Department of Environmental Quality Forms website.

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INSTRUCTIONS FOR PREPARING A
REPORT OF INSPECTION
-
FOR AN ON
SITE WASTEWATER TREATMENT FACILITY
I
NSTRUCTIONS
Any person selling or transferring ownership of a
Qualified Inspector inspects facility
property served by an on-site wastewater treatment
within 6 months before property transfer
facility (including a conventional septic tank system or
and alternative on-site wastewater treatment facility)
must retain a qualified Inspector to inspect the facility
Inspector completes Report of Inspection
within six months prior to transferring ownership of the
and gives to Seller
property, (Arizona Administrative Code, A.A.C. R18-9-
A316). See Figure 1.
Prior to property transfer, Seller gives Report of
An inspector that is qualified under A.A.C. R18-9-
Inspection to Buyer with any other facility
documentation in Seller’s possession
A316, must complete the attached Report of Inspection
form, and provide it to the seller as required by the
Code. If there is more than one on-site system in use
on the property, the Inspector shall complete a Report
Buyer submits Notice of Transfer form
of Inspection form for each system.
with fee to applicable agency
within 15 days after date of property transfer
Before the transfer date (closing date) of the property,
Figure 1. Flowchart of Notice of Transfer Process.
the seller shall provide the buyer with the completed
Report of Inspection form and any other documents in their possession that relate to the permitting or operation
and maintenance of the septic tanks systems or alternative on-site wastewater treatment facility. DO NOT
submit this Report of Inspection form to ADEQ or the local county permitting agency. The Buyer retains
this form after receiving it from the Seller.
Within 15 calendar days after the date of property transfer, the Buyer shall submit a complete Notice of Transfer
form (http://www.azdeq.gov/environ/water/permits/download/presale.doc) for the change of ownership, and file
it with the applicable agency indicated in the Notice of Transfer instructions. Information from this Report of
Inspection form is needed to fill out the Notice of Transfer that must be submitted by the Buyer.
Effective February 2, 2007, you may be able to file your Notice of Transfer online. Go to the ADEQ web
site at http://www.azdeq.gov/environ/water/permits/onsitenot.html for further information regarding
this.
Qualified inspectors are required to completely and accurately fill out this form to the best of their knowledge.
F
GWS 432 (R
,
16, 2007)
P
i
ORM
EVISED
FEBRUARY
AGE
DOWNLOAD THE LATEST UPDATE OF THIS FORM FROM THE ADEQ WEBSITE AT
http://www.azdeq.gov/environ/water/permits/download/inspection.doc
INSTRUCTIONS FOR PREPARING A
REPORT OF INSPECTION
-
FOR AN ON
SITE WASTEWATER TREATMENT FACILITY
I
NSTRUCTIONS
Any person selling or transferring ownership of a
Qualified Inspector inspects facility
property served by an on-site wastewater treatment
within 6 months before property transfer
facility (including a conventional septic tank system or
and alternative on-site wastewater treatment facility)
must retain a qualified Inspector to inspect the facility
Inspector completes Report of Inspection
within six months prior to transferring ownership of the
and gives to Seller
property, (Arizona Administrative Code, A.A.C. R18-9-
A316). See Figure 1.
Prior to property transfer, Seller gives Report of
An inspector that is qualified under A.A.C. R18-9-
Inspection to Buyer with any other facility
documentation in Seller’s possession
A316, must complete the attached Report of Inspection
form, and provide it to the seller as required by the
Code. If there is more than one on-site system in use
on the property, the Inspector shall complete a Report
Buyer submits Notice of Transfer form
of Inspection form for each system.
with fee to applicable agency
within 15 days after date of property transfer
Before the transfer date (closing date) of the property,
Figure 1. Flowchart of Notice of Transfer Process.
the seller shall provide the buyer with the completed
Report of Inspection form and any other documents in their possession that relate to the permitting or operation
and maintenance of the septic tanks systems or alternative on-site wastewater treatment facility. DO NOT
submit this Report of Inspection form to ADEQ or the local county permitting agency. The Buyer retains
this form after receiving it from the Seller.
Within 15 calendar days after the date of property transfer, the Buyer shall submit a complete Notice of Transfer
form (http://www.azdeq.gov/environ/water/permits/download/presale.doc) for the change of ownership, and file
it with the applicable agency indicated in the Notice of Transfer instructions. Information from this Report of
Inspection form is needed to fill out the Notice of Transfer that must be submitted by the Buyer.
Effective February 2, 2007, you may be able to file your Notice of Transfer online. Go to the ADEQ web
site at http://www.azdeq.gov/environ/water/permits/onsitenot.html for further information regarding
this.
Qualified inspectors are required to completely and accurately fill out this form to the best of their knowledge.
F
GWS 432 (R
,
16, 2007)
P
i
ORM
EVISED
FEBRUARY
AGE
DOWNLOAD THE LATEST UPDATE OF THIS FORM FROM THE ADEQ WEBSITE AT
http://www.azdeq.gov/environ/water/permits/download/inspection.doc
REPORT 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
http://www.azdeq.gov/environ/water/permits/download/inspection.doc
REPORT OF INSPECTION
TAX PARCEL NO: ______________ DATE OF INSPECTION:____________
6
S
U
I
(All fields are required)
ITE AND
SAGE
NFORMATION
A) Domestic Water Source:
Municipal System
Private Water Company
Shared Private Well
Individual Private Well
Hauled Water
No Water
B) Approximate Property Size:
Square Feet
Acres
C) Use of Property:
Dwelling or Other Residential
Other (describe):
D) Occupancy/Use:
Full Time
Seasonal/Part time: About____% of year
Intermittent
Vacant
Unknown
If dwelling, number of bedrooms:
1
2
3
4
5
6 or more.
Number of on-site systems in use on this property?
One (most common)
Note: If more than one on-site system is in use on this property, a
More than one (indicate number): ____ Report of Inspection form should be completed for each system.
E) Estimated Design Flow:
gallons per day
Basis for design flow (check either 1 or 2):
1) Designated in permitting documents issued on or after January 1, 2001
2) Calculated or estimated based on (check one):
For a dwelling, number of bedrooms times 150 gallons per day per bedroom
For a dwelling, fixture count as tabulated in A.A.C. R18-9-A314(4)(a)(i)
If not a dwelling, summation of unit flows from Table 1, Unit Design Flows (AAC. R18-9-E323)
Other (describe):
F) Evaluation of actual flow versus the design flow indicated in E:
Actual flow does not appear to exceed design flow
Actual flow may exceed design flow due to:
Number of occupants (high occupancy)
Bedroom count (actual number of bedrooms appears greater than number upon which original design
may have been based)
Fixture count
Water meter/usage records
Other (describe):
Unknown or could not be determined
G) Strength of sewage received by on-site wastewater treatment facility:
Appears representative of typical residential sewage strength
Includes waste from kitchen garbage disposal?
Yes
No
Unknown or could not be determined.
Appears to exceed strength of typical residential sewage because
Appears to be weaker than typical residential sewage because
Unknown or could not be determined
F
GWS 432 (R
,
16, 2007)
P
2 of 7
ORM
EVISED
FEBRUARY
AGE
DOWNLOAD THE LATEST UPDATE OF THIS FORM FROM THE ADEQ WEBSITE AT
http://www.azdeq.gov/environ/water/permits/download/inspection.doc
REPORT OF INSPECTION
TAX PARCEL NO: ______________ DATE OF INSPECTION:____________
7
G
T
D
W
I
(Complete either Section A or Section B)
ENERAL
REATMENT AND
ISPOSAL
ORKS
NFORMATION
The system consists of the following treatment and disposal technologies (check either column A or column B,
and all applicable boxes in the selected column that describe the overall system).
SECTION A
SECTION B
A) System constructed or authorized for
B) System authorized for construction
ON OR
Construction
January 1, 2001
January 1, 2001
BEFORE
AFTER
Conventional Septic Tank System
GP 4.02 Conventional Septic Tank/ Disposal System
Septic Tank
Septic Tank
Disposal Trench
Disposal Trench
Disposal Bed
Disposal Bed
Disposal by Chamber Technology
Disposal by Chamber Technology
Disposal by Seepage Pit
Disposal by Seepage Pit
Other:
Alternative Systems (check all that apply)
Alternative Systems (check all that apply)
Composting Toilet System
GP 4.03 Composting Toilet System
Pressure Distribution System
GP 4.04 Pressure Distribution System
Gravelless Trench
GP 4.05 Gravelless Trench
Natural Seal Evapotranspiration Bed
GP 4.06 Natural Seal Evapotranspiration Bed
Lined Evapotranspiration Bed
GP 4.07 Lined Evapotranspiration Bed
Wisconsin Mound
GP 4.08 Wisconsin Mound
Engineered Pad System
GP 4.09 Engineered Pad System
Intermittent Sand Filter
GP 4.10 Intermittent Sand Filter
Peat Filter
GP 4.11 Peat Filter
Textile Filter
GP 4.12 Textile Filter
Denitrifying System Using Separated Wastewater
GP 4.13 Denitrifying System Using Separated
Streams (e.g., RUCK®)
Wastewater Streams
Sewage Vault
GP 4.14 Sewage Vault
Aerobic System
GP 4.15 Aerobic System
Nitrate-Reactive Media Filter
GP 4.16 Nitrate-Reactive Media Filter
Cap System
GP 4.17 Cap System
Constructed Wetland
GP 4.18 Constructed Wetland
Sand-Lined Trench
GP 4.19 Sand-Lined Trench
Disinfection Devices
GP 4.20 Disinfection Device
Surface Disposal
GP 4.21 Surface Disposal
Subsurface Drip Irrigation Disposal
GP 4.22 Subsurface Drip Irrigation Disposal
Design flow is 3,000 gpd or more
GP 4.23 Design flow from 3,000 to less than 24,000
Other
Gallons Per Day (4.23 GP)
Date of Construction:
Date of Discharge Authorization for system
Based on:
(or Verification if issued from 1/1/2001 through 12/11/2005):
Permitting documentation
Other documentation
Estimated
Unknown Construction Date
C) Date of last inspection and/or pumping of septic tank:
_________ / _____ / __________
Unknown
D) Repairs or alterations to the facility since original installation?
Yes
No
Unknown
E) Is facility currently being serviced under a maintenance contract?
Yes
No
Unknown
F
GWS 432 (R
,
16, 2007)
P
3 of 7
ORM
EVISED
FEBRUARY
AGE
DOWNLOAD THE LATEST UPDATE OF THIS FORM FROM THE ADEQ WEBSITE AT
http://www.azdeq.gov/environ/water/permits/download/inspection.doc
REPORT OF INSPECTION
TAX PARCEL NO: ______________ DATE OF INSPECTION:____________
8
S
T
I
P
I
(for Conventional Septic Systems or Alternative
EPTIC
ANK
NSPECTION AND
UMPING
NFORMATION
Systems that use a Septic Tank)
A) Was the septic tank pumped as part of this inspection?
Yes
No
If No, septic tank was not pumped because:
The septic tank was put into service less than 12 months before inspection
Pumping or servicing was not necessary at the time of inspection based on manufacturer’s written
operation and maintenance instructions (applicable only to alternative technologies).
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).
Additional Information:
B) Septic tank material:
Pre-cast concrete
Fiberglass
Plastic
Other: _________________
Could not be determined
C) Liquid level in septic tank before pumping:
Normal
Below normal
Above normal
Could not be determined
D) Access openings in septic tank:
One
Two
Three
None
Other (describe) _________
___________________________________________________________________________________________
E) Number of compartments in septic tank:
One
Two
Other (describe) _____________________
___________________________________________________________________________________________
F) Depth of soil cover over tank access port or riser:
inches or
feet
G) Septic tank risers:
Present
Not present
H) Capacity of septic tank:
gallons
Based on:
Measurements/dimensions of tank
Volume Pumped
Estimate
Capacity could not be determined
I) Scum/Sludge (measured before pumping):
i) Tank depth (air-liquid interface to bottom of tank:
ft
inches
ii) Primary (upstream) chamber:
Scum depth ____ inches, Sludge depth ____ inches
iii) Secondary (downstream) chamber: Scum depth ____ inches, Sludge depth ____ inches
J) Baffle or sanitary “T” material:
Pre-cast concrete
Fiberglass
Plastic
Clay
Other: ___________________
K) Condition of baffles and sanitary “Ts”:
i) Inlet baffle or “T”:
Functional
Not functional
Not present
Not determined
ii) Outlet baffle or “T”:
Functional
Not functional
Not present
Not determined
iii) Interior baffle:
Functional
Not functional
Not present
Not determined
L) Is there evidence of leakage into septic tank (infiltration)?
Yes
No
Could not be determined
M) Is there evidence of leakage out of the septic tank (exfiltration)?
Yes
No
Could not be determined
N) Is there evidence of :
Root invasion
Cracks in tank
Damaged lids or risers
Other (describe): ___________________________________________________
O) Is a sewer line cleanout present between building drain and septic tank?
Yes
No
Not determined
P) Effluent filter:
Present
Not present
Could not be determined
Filter serviced.
Q) Repairs or other maintenance done to septic tank as part of this inspection?
No
Yes
(describe at Item 12B)
F
GWS 432 (R
,
16, 2007)
P
4 of 7
ORM
EVISED
FEBRUARY
AGE
DOWNLOAD THE LATEST UPDATE OF THIS FORM FROM THE ADEQ WEBSITE AT
http://www.azdeq.gov/environ/water/permits/download/inspection.doc

Download ADEQ Form GWS 432 Report of Inspection of an on-Site Wastewater Treatment Facility - Arizona

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