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Property address: <br />City: <br />5. Is the tank designed as a leaky tank? (Example: seepage pit, cesspool, drywell, leaching pd) <br />Parcel ID: <br />Zip code: <br />Tank #1: ❑ YesNo Verification method used: U IS__y uRL <br />Tank #2: ❑ Yes f No Verification method used: I, tSkJAL <br />6. Is there evidence of the following? <br />Tank leaks below the I Tank Wake above the <br />Tank #1 <br />Yes <br />Describe detail for any "Yes" <br />7. How many gallons of septage were removed? '3 <br />Tank #1: TanK #2: r /j >& Pretreatment Tank: <br />Maintenance hole cover is <br />damaged, cracked, unsecured, or <br />-,Tm <br />Pump Tank: SZXD <br />S. Where was the septage taken? 0 Wastewater treatment facility ❑ Land application ❑ Other <br />Explanation (Facility name/Site t): <br />9. Did you ntlfy any operational issues or unsafe conditions while assessing the sewage tanks in this system? <br />❑ Yes No If yes, identify tank and explain: <br />❑ d nee 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 />0 As a noncertified individual who has received proper training, dairy work review, and periodic observation, or <br />❑ As a designated certified individual of the business listed below. <br />By typing/signing my moors 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 <br />Company name: Mike's Septic & McKinley Sewer <br />Business license number: L 19385 & L2899 <br />Email: <br />Employee's signature: <br />Employee it#oNnation <br />Print name: i" % ` VIJQ tnJ lea \ gtA[fS— — <br />Certification number. (of applicable): <br />Phone number. 952.440.1800 <br />Date (mm/dd/ylyyy)- <br />vmw.pca.state.rnn.us 651-296.6300 800.6573864 Use your preferred relay service Available in alternative formats <br />wq-wwist54-38 • 4118/21 Page of <br />