On-Line Application

Service Request Form/Service Agreement

Terms of Agreement:

All costs of collection, attorney fees, liens on properties, etc. shall be paid by Applicant in the event of legal action is filed by Enviroappraisal LLC to collect amounts due. Interest on any past due amount over 45 days will be at the rate of 10% per annum.

Property Address (include Subdivision & Lot # if applicable)
County	Township
Tax ID Number	Expected Closing Date
Owner/Buyer	Owner/Buyer Cell Phone	Owner/Buyer Home Phone
Owner/Buyer Mailing Address
Realtor's Name	Realtor's Company	Realtor's Email Address
Realtor's Office Phone	Realtor's Cell Phone	Realtor's Fax Number
Realtor's Mailing Address
Contact for service needs/ arrangements? Owner Realtor Broker Other		If "Other", Who?
Send Report via Fax Email Mail
Is there electric power? Yes No
Is the property vacant? Yes No
If yes, how long?
Has the home been winterized? Yes No
House dewinterized and water ran and ready to sample? Yes No
Keybox or combo/code box?
Is there any additional info (owner septic diagram, pump receipt, realtor info, etc.)? Yes, will provide (use additionl info and file upload below.) No
Services Requested: Septic Only - Includes open/close septic $200.00 Well Only - Includes lab fee $200.00 Septic and Well, Includes open/close septic & lab fee- $300.00 Well dewinterize/Rewinterize - $75.00/well Locate and expose system for Inspection and Evaluation - $90.00/hr., 1 hour min. Pump Septic Tank - $235.00/1000 gal. paid from client to Enviroappraisal LLC to Septic Pumper selected. Raw Land Evaluation - $200.00 Lead Water Analysis $20.00 (5 day) $40.00 (2 day) - Fee paid by realtor/client BEDHD TOST Program requires additional $94.00 fee well or septic only; well and septic fee $153.00. This fee must be paid up front to submit info to BEDHD.
Payment: Completion of Service At Closing (within 30 days) Check Mailed Credit Card
By submitting this form, I agree to the terms above.
Date of Submission
Additional Info:
Select A File To Upload:

Enviroappraisal, LLC.
Matt Strole, Certified Environmental Consultant
PO Box 347, Richland, MI 49083
office 269-753-1137 | cell 269-303-4652 | fax 269-753-1138