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Property address: <br />City: _Orono _ <br />5 <br />6. <br />2400 Fox Street <br />Parcel ID <br />State: MN Zip code <br />Is the tank designed as a leaky tank? (Example: seepage pit, cesspool, drywell, leaching pit) <br />Tank #1: ❑ Yes ❑ No Verification method used: VISUAL <br />Tank #2: ❑ Yes 0 No Verification method used: VISUAL <br />Is there evidence of the following? <br />0411723410011 <br />55391 <br />7. How many gallons of septage were removed? <br />Tank #1: 1000 Tank #2: 1000 Pretreatment Tank: Pump Tank: 300 _ <br />8. Where was the septage taken? ® Wastewater treatment facility ❑ Land application ❑ Other <br />Explanation (Facility name/Site #): Watertown <br />9. Did you identify any operational issues or unsafe conditions while assessing the sewage tanks in this system? <br />❑ Yes ® No If yes, identify tank and explain: <br />❑ Evidence of non-domestic waste ❑ Baffie(s) condition ❑ Effluent screen condition <br />❑ Maintenance hole and extensions condition ❑ Other conditions (e.g. structural integrity of tank or lid, electrical hazard, etc.) <br />Explanation: <br />10. List any troubleshooting and minor repairs completed or declined by owner: <br />❑ Troubleshooting and repairs conducted: I ❑ Repairs declined by owner: <br />Additional comments or suggestions for owner's consideration: <br />A filter is installed in the2nd tank and should be pulled and flushed twice a year <br />Pumping record <br />I personally conducted the work described above on behalf of a Minnesota -licensed SSTS Maintenance Business, in compliance <br />with Minnesota Rules Chapters 7080 — 7083: <br />❑ As a noncertified individual who has received proper training, daily work review, and periodic observation, or <br />® As a designated certified individual of the business listed below. <br />Company information Employee information <br />Company name: Chip Septic Services — Print name: Pernel Hentges <br />Business license number: 2064 <br />Email <br />Employee's signature: <br />Certification number: (if applicable): <br />Phone number: 952-200-3176 <br />Date (mmlddlyyyy): 613012020 <br />vrww.pca.state.mn.us • 651-296-6300 800-657-3864 Use your preferred relay service Available in alternative formats <br />wn-wwkh;4- 3R . 1/27/17 Pa4e 2 of 3 <br />Maintenance hole cover is <br />Tank leaks below <br />the <br />Tank leaks above the <br />damaged, cracked, unsecured, or <br />__Tank (check if present) <br />designed operating depth <br />designed operating depth <br />appears to be structurally unsound <br />Septic/holding Tank #1 <br />1 ❑ Yes <br />E No <br />❑ Yes <br />®No <br />❑ Yes ® No <br />® Septic/holding Tank #2 <br />i ❑ Yes <br />®No <br />❑ Yes <br />0 No <br />❑ Yes ® No <br />❑ Pretreatment Tank <br />A ❑ Yes <br />❑ No <br />❑ Yes <br />❑ No <br />❑ Yes ❑ No <br />Pump Tank _ _ <br />[❑ Yes <br />® No <br />❑ Yes <br />® No ..... <br />i .---[]Yes O No <br />Describe detail for any "Yes" <br />7. How many gallons of septage were removed? <br />Tank #1: 1000 Tank #2: 1000 Pretreatment Tank: Pump Tank: 300 _ <br />8. Where was the septage taken? ® Wastewater treatment facility ❑ Land application ❑ Other <br />Explanation (Facility name/Site #): Watertown <br />9. Did you identify any operational issues or unsafe conditions while assessing the sewage tanks in this system? <br />❑ Yes ® No If yes, identify tank and explain: <br />❑ Evidence of non-domestic waste ❑ Baffie(s) condition ❑ Effluent screen condition <br />❑ Maintenance hole and extensions condition ❑ Other conditions (e.g. structural integrity of tank or lid, electrical hazard, etc.) <br />Explanation: <br />10. List any troubleshooting and minor repairs completed or declined by owner: <br />❑ Troubleshooting and repairs conducted: I ❑ Repairs declined by owner: <br />Additional comments or suggestions for owner's consideration: <br />A filter is installed in the2nd tank and should be pulled and flushed twice a year <br />Pumping record <br />I personally conducted the work described above on behalf of a Minnesota -licensed SSTS Maintenance Business, in compliance <br />with Minnesota Rules Chapters 7080 — 7083: <br />❑ As a noncertified individual who has received proper training, daily work review, and periodic observation, or <br />® As a designated certified individual of the business listed below. <br />Company information Employee information <br />Company name: Chip Septic Services — Print name: Pernel Hentges <br />Business license number: 2064 <br />Email <br />Employee's signature: <br />Certification number: (if applicable): <br />Phone number: 952-200-3176 <br />Date (mmlddlyyyy): 613012020 <br />vrww.pca.state.mn.us • 651-296-6300 800-657-3864 Use your preferred relay service Available in alternative formats <br />wn-wwkh;4- 3R . 1/27/17 Pa4e 2 of 3 <br />