09/06/2018 Septic Compliance - Laserfiche WebLink

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Reporting Information Date of maintenance: Property address: Property owner's nanL: Property -owner's address if different: City: State: Reason for maintenance�a t . .�� -...__. City: c`v z Stater Zip: Zip: Phone: Fax: 1. Access used to remove septage: C. Maintenance hole ❑ Other (Go to #3 below) 2. If maintenance hole was used, were all covers securely replaced? Yes ❑ No please explain Explanation: 3, If owner refuses to allow a Subsurface Sewage Treatment System (SSTS) to be pumped through the maintenance hole, have them complete and sign the following statement. I, ___, refuse to allow the removal of the solids and liquids through the maintenance (Owner's name) _ - hole. I understand that removal of solids and liquids through other access points is not considered maintenance. Owner's signature: Date: 4. Is the tank designed as a leaky tank? (Example: seepage pit,. cesspo¢ , drywell, leaching pit) Tank #1: ❑ Yes V No Verification method used? Tank #2: ❑ Yes No Verification method used? 5. Is there evidence of tank leakage from a septic, holding, pretreatment or pump tank below the operating depth or evidence of damaged, cracked or structurally unsound maintenance hole covers? Tank Leaking out ! Leaking in Cover damage Septic/hQldin Tank #1 E Yes �9 No ❑ Yes No I E]Yes bg No ------- --- Se�ticlholdingTank #2 i El No _ El Yes No f Yes No Pretreatment Tank ❑ Yes ❑ No ❑ Yes ❑ No ❑Yes ❑ No Pump Tank ❑Yes �(] No ❑ Yes No ❑ Yes No 6. How many gallons of septage were removed? Tank #0\n'\') Tank #2: } v�� Pretreatment Tank: Pump Tank 7. Is there any sensory (smell and/or sight) evidence of non-domestic wastes? ❑ Yes �[-!'§P'No Please explain: Disposal site: \C] Wastewater treatment plant ❑ Land application ❑ Other (please explain below) Explanation: List any troubleshooting, minor repairs conducted, tank safety* concerns or other concerns: B. Certification: I hereby certify as a State of Minnesota -certified SSTS Maintainer that I personally conducted the work and made the observations, or directly supervised others in the performance of this job. Maintainer's name and address: C`35 Maintainer's license Maintainer's phone: Maintainer's signature: `i`a� DateN��\R i www.pca.state.mn.us • 651-296-6300 • 800-657-3864 TTY 651-282-5332 or 800.657-3864 • Available in alternative formats wq-wwlsts4.38 • 9123110 Page 2 of 2