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Property address: „1580 County Rd 6 (6th Ave N)_ ___.. _ _. _. Parcel ID: 2611823320006 <br />city: .. Orono _ State: MN' .. _ __ zip code: _55356 <br />5. Is the tank designed as a leaky tank? (Example: seepage pit, cesspool, dryweil, leaching pit) <br />Tank #1: ❑ Yes 9 No Verification method used: Visual when empty <br />Tank #2: ❑ Yes 0 No Verification method used: Vlaval when empty <br />G. Is there evidence of the following? <br />Maintenance Note cover is <br />Tank tc Lack if presentt __. <br />Tank teaks below the <br />designed operating depth_ <br />Tank teaks above the I damaged, cracked, unsecured, or <br />designed opera f_dng epth _ vpears to be structurally unsound , <br />_RSeptid pIdin Tank #1 _ <br />_ 0 Yes _® No -- <br />_ _ . _ Yes ®No _ <br />__ + _ IT* <br />Rl Septialholding Tank#2 <br />❑ Yes _J@No <br />_rl yes RNo <br />—0—yes ENP <br />Pretreatment Tsnk - _-_ <br />❑ Yes El No <br />_ Yes_ Q No--- <br />_ _ [j Yes No <br />_ <br />Pum Tp ank -- <br />_ (� Yes ® No_ .. <br />❑ YesZ No <br />Describe detail for any `Yes" <br />7. How many gallons of septage were removed? <br />Tank #1: 1250 Tank #2: 1250 Pretreatment Tank: Pump Tank: 100 <br />8. Where was the septage taken? E Wastewater treatment facility ❑ Land application ❑ Other <br />Explanation (Facility name/Site #): Watertown, M N <br />9. Did you identify any operational Issues or unsafe conditions whits assessing the sewage tanks in this system? <br />❑ Yes ® No If yes, identify tank and explain: <br />❑ Evidence of non-domestic waste ❑ Baftle(s) condition ❑ Effluent screen condition <br />❑ Maintenance hole and extensions condition ❑ Other conditions (e.g. structural integrity of tank or lid, electrical hazard, eta) <br />Explanation: <br />10. List any troubleshooting and minor repairs completed or declined by owner: <br />switch. All baffles present & in good condition. <br />Additional comments or suggestions for owner's consideration: <br />Pumping record <br />I personally conducted the work described above on behalf of a Minnesotedicensed SSTS Maintenance Business, in compliance <br />with M/nnesote Rules Chapters 7080 - 7083: <br />❑ As a noncertiffed individual who has received proper training, daily work review, and periodic observation, or <br />IRAs a designated certified individual of the business listed below. <br />By 010 ping 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 Employee Information <br />Company name: Albin's_ Septic Pumping, LLC Print name: Peter Peterson <br />Business license number: 3346 Certification number: (if applicable): 9227f <br />Email: albinssepticpum ' g ahoo.com Phone number: 612-559-3456 <br />Employee's signature:'" Date (mmlddMrYY) <br />www.pca,state.mn.us <br />wq-wwfsts4-38 • 1/7/21 <br />651-296-6300 • 800-657-3864 use your preferred relay service • Available in alternative formats <br />Page 2 of 3 <br />