Effluent pumpout change of frequency form

Please fill in all of the fields on the form below where applicable.

 

Owner/Agent details

     
 
Title
  
Mr Mrs Miss Ms  
 
 
Full name
   
 
Telephone - home
    
 
Telephone - mobile
   
 
     
 

Street address

  
 
Street number
   
 
Road / Street
    
 
Suburb/Town
    
 
Postcode
    
 
     

Postal address (if different from street address)

 
 
Street number
   
 
Road / Street
   
 
Suburb/Town
    
 
Postcode
    
 
     

Removal frequency

  
 
Current frequency
   every     weeks  
 
Requested frequency
   every     weeks  
 
     
 
Comments
    
         
 
Declaration
   I being the owner/agent for the above property, do hereby request Shoalhaven City Council to change the Effluent Removal Frequency, as indicated on this form, until further notice and adjust my rates assessment accordingly.