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Septic Tank Pumping / Maintenance <br />Owner Information <br />Date: a//n / /o <br />Owner: Phone#: <br />Property address: Owners address: (if different) <br />2770 1& -1 <br />!�f zr—A 1'"A4 <br />Tank Information <br />Reason for Pumping: L-' compliance inspection ❑ holding tank ❑ maintenance <br />Method of access: �anholes ❑ inspection pipe (holding tanks only) <br />(owner signature req'd if refusing to allow pumping through maintenance hole) <br />Condition of tanks: <br />filter cleaned: Yes baffles good: Yes alarm working: es <br />No <br />n/a n/a n/a <br />Tank leakage obs ed: above operating depth: Yes o (repairs recommended) <br />below operating depth: Yes (failing to protect groundwater) <br />Gallons removed: <br /># 1 1(y)() #2 j 0 pry #3 #4 pump tank total z-Zj U <br />Disposal method: municipal x/ location: <br />land apply ❑ location: <br />Safety concerns: <br />Recommended repairs: <br />Comments: <br />/Ju,...k.i e�^�., 3 lrzva <br />I hereby certify that 1 have completed this work in accordance with MN 7083.0770 and any local requirements. <br />N,�: '�ationorntee offuture system performance has been nor can be made. <br />Chip's Septic Service, LLC SSTS License <br />Maintainer signature 16762 Babcock Avenue #2064 <br />Lester Prairie, MN. 55354 <br />(952)200-3176 <br />