Laserfiche WebLink
Property address: �2—j 0 <br />Parcel ID: <br />City: D'rd nn <br />State:®� <br />Zip code: <br />5. Is the tank designed as a leaky <br />tank? (Example: seepage pit, cesspool, dlywell, leaching pit) <br />Tank #1: ❑ Yes 2No <br />Verification method used: <br />Tank #2: ❑ Yes--ffNo <br />Verification method used: <br />6. Is there evidence of the following? <br />Maintenance hole cover is <br />Tank leaks below the <br />Tank leaks above the <br />damaged, cracked, unsecured, or <br />Ta k (check if present) <br />designed operating depth <br />designed operating depth <br />appears to be structurally unsound <br />Septic/holding Tank #1_ <br />❑ Yes No <br />❑ Yes jZrNo <br />❑ Yes <br />Septic/holding Tank #2 <br />❑ Yes No <br />_ _ ❑ Yes/No <br />_ ❑ Yes.] No <br />❑ Pretreatment Tank <br />❑ Yes El No <br />❑ Yes El No <br />- <br />_ ❑ Yes ❑ No <br />.'Pump Tank <br />❑ Yes No <br />0 Yes No <br />E] Yes No <br />Describe detail for any "Yes" <br />7. How many gallons of septage were removed? <br />Tank #0 � ()_ Tank #2: Pretreatment Tank: Pump Tank: <br />8. Where was the septage takenWastev"ter treatment facility ❑ Land application ❑ Other <br />Explanation (Facility name/Site #): <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. List any troubleshooting and minor repairs completed or declined by owner: <br />Additional comments or suggestions for owner's consideration: <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 />By typing/signing 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 informati in F Employee informatio <br />Company name: / �� 1 ( _ Print name: ( <br />✓ <br />5_ <br />Business license number: D6� _ Certification number: (if applicable): <br />Email: Phone number: <-/ 6i0 <br />Employee's signature: =/G65'�' Date (mm/dd/yyyy):-- <br />www.pca.state.mn.us 651-296-6300 • 800-657-3864 Use your preferred relay service Available in alternative formats <br />wq-ww1sts4-38 • 117/21 Page 2 of 3 <br />