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Property address: 2675 Fox St - Parcel ID: 0411723430003 <br />city: Orono state: MN zip code: 55391 <br />5. Is the tank designed as a leaky tank? (Example: seepage pit, cesspool, drywell, leaching pit) <br />Tank #1: ❑ Yes ❑ No Verification method used: _ Tank #2: ❑ Yes ❑ No Verification method used: - <br />S. Is there evidence of the following? <br />intanan hole cover is <br />Tank;check If presentZ _ _ _ .. <br />Sep#clhoidin Tank #1 <br />Septiclholding Tank #2 <br />Pretreatment Tank _ <br />Describe detail for any "Yes" <br />Tank leaks below the <br />designed operating depth <br />Tank leaks above the <br />designed operating depth_ <br />� Ma ce <br />damaged, cracked, unsecured, or <br />�.>_ appeaMto bi st^ict ally unsound <br />Yes <br />Na <br />Yes � No _ <br />No <br />-+ �- .Y�es ------- <br />_ _[7 <br />❑ Yes_No <br />_�I <br />. ❑ Yes. _No YesNo <br />® Yes <br />❑ No <br />Yes [jNo� <br />-F.. fl Yes No _- — <br />_❑ Yes <br />0 No_ <br />El Y@;;__0 No , _ _ <br />Yes No <br />� �� o.._ <br />7. Now many gallons of septage were removed? <br />Tank #1: 1000 Tank #2: 1000 Pretreatment Tank: x Pump Tank: 100 <br />8. Where was the septage taken? 0 wastewater treatment facility ❑ Land application ❑ Other <br />Explanation (Facility name/Site #): _Vllatertown, M N - — —� - <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 ❑ Baffle(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. hist any troubleshooting and minor repairs completed or declined by owner: <br />X Troubleshooting and repairs conducted: Y ❑ Repairs declined by <br />RenlarPd alarm float switch in the Dump tank., <br />Cleaned effluent filter w/alarm in 2nd tank outlet.; _ <br />Additional comments or suggestions for owner's consideration: <br />Pumpinr 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 />By typinoigning my name below, I certify the above statements to be true and correct, to the best of my knowledge, and that <br />this information can be used for the purpose of processing this form. <br />Company information <br />Company name: Albin's Septic Pumping, LLC <br />Business license number: 3346 <br />Email: albinsseptic uymp ing ahoo.com <br />Employee's signature: <br />Employee information <br />Print name: Peter Peterson <br />Certification number. (if spoicgue): 9227 e <br />Phone number. 612-559-3456 _ <br />-�- - Date (mm/ddJ"):_ 10/02/2021 _ _ _— <br />www.pca.state.rnn.us • 651-296-6340 • 800-657-3864 use your preferred relay service Available in alternative formats <br />wq-wwists4-38 • 117121 Page 2 of 3 <br />