A&B Septic Service

Albany: 541-924-0851             Salem: 503-393-1311             Coast: 541-574-1656

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Type of Services you require: (select one) Pumping: Septic/Holding Tanks/Other
Line & Drain Cleaning
Line Repair
Cleaning Line to City
Pump System Service
Pump System Maintenance
Electronic Locating
Operation & Maintenance
Onsite Management
Other Services
Service is for: (select one) Residence
Real Estate Transaction
Other Service
First Name:
Last Name:
Billing Address:
Zip Code:
Enter one or more of your phone numbers where you would like us to call you back.
At least one phone number is required please.
Work Phone:
Home Phone:
Mobile Phone:
E-Mail Address: *Required
How would you like to be contacted? Email     Mail     Fax     Phone
Requested Service Date:
Requested Service Time:
Type of System: (select one) Gravity
Sand Filter
Pump System
Recirculating Gravel Filter
Other Type
Job Address:
Job City:
Job State:
Job Address Phone:
Do you need an inspection? Yes    No
Date Last Pumped:
Number of Occupants:
Number of Bedrooms :
Location of Tank, if known:
Tank Portal Exposed?
Yes    No
Number of Acres:
Property Owner Name:
If Vacant, How Long?
Fax Inspection Report to:
Fax Number
Mail Invoice & Inspection Report to:
Directions to Job Site Starting with Major Street, Hwy or Freeway:
Explain Problems you are having with System:

If you feel it is time to have your system serviced or if you have any questions, please give us a call at
Salem: 503-393-1311
Albany: 541-924-0851
Coast: 541-574-1656
Toll Free: 1-866-927-1156

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