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Property address: 2700 White Oak Circle Parcel ID: 0411723420021 <br />City: Orono State: MN Zip code: 55356 <br />5. Is the tank designed as a leaky tank? (Example: seepage pit, cesspool, cltywell, leaching pit) <br />Tank #1: 0 Yes El No Verification method used: visial <br />Tank #2: 0 Yes El No Verification method used: visial <br />6. Is there evidence of the followin ? <br />Tank (check if present) <br />Tank leaks below the <br />designed operating depth <br />Tank leaks above the <br />designed operating depth <br />Maintenance hole cover is <br />damaged, cracked, unsecured, or <br />appears to be structurally unsound <br />• Septic/holding Tank #1 • Yes • No • Yes IN No Yes • No <br />• Septic/holding Tank #2 MI Yes II No M Yes M No Yes III No <br />II Pretreatment Tank II Yes II No • Yes MI No • Yes • No <br />II Pump Tank • Yes • No I Yes II No • Yes No <br />Describe detail for any "Yes" <br />7. How many gallons of septage were removed? <br />Tank #1: Tank #2: Pretreatment Tank: Pump Tank: <br />8. Where was the septage taken? 0 Wastewater treatment facility 0 Land application 0 Other <br />Explanation (Facility name/Site #): <br />9. Did you identify any operational issues or unsafe conditions while assessing the sewage tanks in this system? <br />El Yes LI No If yes, identify tank and explain: <br />0 Evidence of non-domestic waste 0 Baffle(s) condition 0 Effluent screen condition <br />El Maintenance hole and extensions condition El Other conditions (e.g. structural integrity of tank or lid, electrical hazard, etc.) <br />The septic tanks structural integrity of the side walls are failing. Concrete was flacking off the walls above the <br />Explanation: water line. Was able to poke hole through the concrete with tile probe. <br />10. List any troubleshooting and minor repairs completed or declined by owner: <br />0 Troubleshooting and repairs conducted: 0 Repairs declined by owner: <br />Additional comments or suggestions for owner's consideration: <br />Septic tanks will need to be replaced. <br />Pumping record <br />I personally conducted the work described above on behalf of a Minnesota-licensed SS TS Maintenance Business, in compliance <br />with Minnesota Rules Chapters 7080— 7083: <br />0 As a noncertified individual who has received proper training, daily work review, and periodic observation, or <br />El As a designated certified individual of the business listed below. <br />Company information Employee information <br />Company name: Chip's Septic Services LLC Print name: Pernel Chip Hentges <br />Business license number: 2064 Certification number (if applicable): <br />Email: chipseptic@gnnail.co Phone number: 952-200-3176 <br />Employee's signature: Date (mm/dd/yyyy): 3/2/2021 <br />www.pcastate.mn.us • 651-296-6300 • 800-657-3864 • Use your preferred relay service • Available in alternative formats <br />wq-ww1sts4-38 • 10/12/18 Page 2 of 3