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Septic Service, LLC <br />1205 LaBeaux Ave NE <br />St. Michael, MN 55376 <br />DATE -3-Z2 <br />Maintenance Inspection Form <br />MPCA Lic. # 654 <br />Maintainer Jim <br />D Duane <br />[&Nick <br />• Phone: 763-497-2764 <br />• Email: duaneseptic@centurylink.net <br />INVOICE <br />Pumping Fee: <br />Scum/Sludge Measured <br />Name: <br />Reason For Pumping: <br />❑ Other (see attached) <br />❑ Yes Rr"No <br />�s ❑ No <br />4 <br />❑ Risers leaking <br />❑ Risers leaking <br />Long Pull Fee: <br />❑ Elevated drainfield <br />Address: <br />❑ Baffles <br />❑ Baffles <br />❑ Pressure bed <br />❑ Non-domestic waste <br />❑ Non-domestic waste <br />❑ Electrical issues <br />❑ Trenches <br />Other Repairs: <br />City/State/Zip: <br />❑ Ponding/Surfacing <br />❑ Effluent Filter/screen <br />/Vu,e 1 e. P <br />Cleaned? ❑ Yes ❑ No <br />Total Cost of Service:Payment <br />Comments: 4 �r �-��t e�-3 `� S} 'CAA, u <br />Method: 0 Check ❑ Cash <br />0 Credit <br />3 <br />Tank (check If present) <br />Tank leaks below the <br />Tank leaks above the <br />Maintenance hole cover is damaged, <br />cracked, unsecured, or appears to be <br />designed operating depth <br />designed operating depth <br />structurally <br />unsound <br />❑ Septic/holding Tank #1 <br />Gallons: <br />❑Yes <br />Ifo <br />❑Yes <br />I] Yes <br />P_" <br />❑ Septiclholding Tank #2 <br />Gallons; <br />❑Yes <br />e'No <br />El Yes quo <br />❑Yes <br />2 -Ivo <br />❑ Pretreatment Tank <br />Gallons: <br />❑ Yes <br />❑ No <br />❑ Yes ❑ No <br />❑ Yes <br />❑ No <br />❑ Pump Tank <br />Gallons: <br />❑ Yes <br />I-_�No <br />❑ Yes Gd'No <br />ElYes <br />B No <br />How Accessed:❑-Wintenance Hole <br />Scum/Sludge Measured <br />Maintenance Holes Securely Replaced: <br />Reason For Pumping: <br />❑ Other (see attached) <br />❑ Yes Rr"No <br />�s ❑ No <br />4 <br />Did you identify any operational issues or unsafe conditions while assessing the sewage tanks in this system, i.e., <br />cracked tanks, missing baffles, broken covers, etc.? If so, explain In comments below, <br />Tank #1 ❑ Yes o <br />Tank #2 ❑ Yes No <br />Pump Tank ❑ Yes ffrNo <br />System <br />O Structural integrity <br />❑ Structural integrity <br />❑ Structural integrity <br />ound <br />❑ Risers leaking <br />❑ Risers leaking <br />❑ Risers leaking <br />❑ Elevated drainfield <br />❑ Baffles <br />❑ Baffles <br />❑ Baffles <br />❑ Pressure bed <br />❑ Non-domestic waste <br />❑ Non-domestic waste <br />❑ Electrical issues <br />❑ Trenches <br />❑ Non-domestic waste <br />❑ Ponding/Surfacing <br />❑ Effluent Filter/screen <br />❑ Other: <br />Cleaned? ❑ Yes ❑ No <br />Comments: 4 �r �-��t e�-3 `� S} 'CAA, u <br />LO .� SAYS 6-«)J J.5o Cle,,, 4-+P M:AAk"II Z-.4. 4/Z // <br />Disposal: Band Application: ❑ Wastewater Treatment Plant <br />Disposal Site: Lime: Gallons -2 PO Plowed: ❑ Yes ❑ No <br />Time: q I 1 Temperature: S 7 pH: 12.3 > 12 <br />Time: '941 Temperature: 5-`7 pH: 12.1 > 12 <br />-�.� C������,� � • �, �� ® �'.-..� _ Com' ����„� � <br />