Laserfiche WebLink
Property address: /10 � � r � low bf r-Cok Cr. Parcel ID: <br />City: iO State: VV Zip code: <br />5. Is the tank designed <br />a leaky tank? (Example: seepage pit, cesspool, drywelf, leaching pit) <br />Tank #1: El Yes Verification method used: <br />Tank #2: ❑ Yes PrNo Verification method used: <br />6. Is there evidence of the following? <br />Maintenance hole cover is <br />Tank teaks below the Tank leaks above the damaged, cracked, unsecured, or <br />7a k check if present) designed operating depth designed oper-4ing depth appears to be structurylly unsound <br />71,SepticJholdingTank #1 ❑ Yes RIVo ❑ Yes o ❑ Yes 9No <br />7ffSe tic/holding Tank #2 ❑ Yes Y No ❑ Yes Z No ❑ Yes No <br />❑ retreatment Tank ❑ Yes allo ❑ Yes ❑ Ko <br />El Yes ❑ <br />Pum Tank El Yes No ❑ Yes No <br />❑Yes No <br />Describe detail for any "Yes' <br />7. Flow many gallons of septage were re045 <br />Tank #1: o Tank #2: _ Pretreatment Tank: Pump Tank: 3d Is <br />' 7 <br />8. Where was the septage taken? ® Wastewater treatment facility ❑ Land application ❑ Other <br />Explanation (Facility name/Site #): Blue Lake <br />9. Did you ;PN*o <br />' y any operational issues or unsafe conditions while assessing the sewage tanks in this system? <br />❑ Yes 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 />❑ Troubleshooting and repairs conducted: I ❑ Repairs declined by owner: <br />Additional comments or suggestions for owners consideration: <br />Pumping record <br />1 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 typinglsigning my narne 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 lln tion <br />Company name: Mike's Septic & McKinleySewer Print name:, <br />Business license number: L 1665 & L2899 Certification number. oifapplicable): <br />Email: Phone number: 952.440-1800 <br />Employee's signature: Crate (mmlddiyyyy): <br />www.pca.state.mn.us 651-296-6300 • 800-657-3864 • Use your preferred relay service • Available in alternative formats <br />