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Property address: 2675 Fox St _ Parcel ID: State: 04117234.30043 <br />city` _rono MN Zip code: 55391 _ } <br />. • . _ . — - - - <br />ti. Is the tank designed as a leaky tank? (Example: seepage pit cesspool, drywell, leaching pity <br />Tank #1: ❑ Yes ❑ No Verification method used: <br />Tank #2: ❑ Yes ❑ No Verification method used: _.._ <br />6. Is there evidence of the following? <br />Tank [chock ifay!!!M§ .. <br />_aSeptir1holdingTank #1 <br />ho41ng Tank #2 <br />�_retrea meat Tank <br />Pump Tank _ <br />Dencribe detail for any "Yes" <br />Tank feake below the <br />dealgn_ed operating depth <br />3 Yes $X No <br />❑ Yes �uNo <br />❑ Yes ❑ No. <br />❑ Yes E9 <br />Maintwmmm Hole cover Is <br />Tank leaks above the ; damaged, cracked, unsecured, or <br />designed operationa.PPeam to bs structxraluriscsuund - <br />Yes _l No + _ [1Yes R No, <br />Yes �Nor7l Yes 19 No <br />No <br />171 Yes [:LNO <br />❑ Yes No t--- A- Yes ps_M No O _ <br />r <br />s <br />7. How many gallons of septage were removed? <br />Tank #1. 1000 Tank #2; 1000 Pretreatment Tank: X _ Pump Tank- 100 <br />$, Where was the septage taken? ® Wastewater treatment facility ❑ Land application ❑ Other <br />Explanation (Facility name/Site #): _VVatertown, MflL—- <br />9. Did you identify any operational issues or unsafe conditions while assessing the sewage tanks In this system? <br />l❑ Yes lel 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, e1wrical hazard, etc.) <br />Explanation: <br />10. List any troubleshooting and minor repalre completed or declined by owner. <br />Troubleshooting and repairs conducted: _ _. ❑ Repairs declined b <br />Replaced alarm float switch in the pump tank., <br />Gleaned effluent filter wlalarm in 2nd tank outlet.' <br />Additional comments or suggestions for owner's consideration: <br />Pumping record <br />1 personally canduclbd firs work described above on behalf of a Minnosola-licensed SSTS Maintenance Business, in corruptions <br />with Minnesota Rules Chapters 7080 - 7083: <br />❑ As a none ertified individual who has received proper training, daily work review, and periodic observation, or <br />JR As a deaignated certified individual of the business listed below. <br />By typin~g my dame below, I certify the above statements to be true and c onci, to the best of my knowledge, and that <br />this infonmation 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: 334_6 <br />Email: albinsseptic urn inJ�?ayahoo.com <br />Employee's signature: <br />www.pca.swe.mmus fi51-29fr63rat7 aw-07-38M <br />w¢wwFsts4.38 ■ 1/7/21 <br />Employee Information <br />Print name: Peter Peterson . <br />Certification number: (it apprr Nap 9227 <br />T Phone number. 612-559-3456 <br />Date (mmlddlyyyy);- 1Q/02/2021 <br />■ Use your preferred relay ser4im AvaVable in aftemative formats <br />Page 2 of 3 <br />