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Septic Service, LLC <br />1205 LaBeaux Ave NE <br />St. Michael, MN 55376 <br />DATE �-- Z & '2-3 <br />Maintenance Inspection Form <br />MPCA L4286 <br />Maintainer F --- I Jim <br />F-1 Duane <br />9PTIck <br />• Phone: 763-497-2764 <br />• Email: duaneseptic@centurylink.net <br />INVOICE <br />Pumping Fee: <br />(�6-- <br />Name: <br />rAk s Pa t%-A <br />Long Pull Fee: <br />Address: <br />0 z T- (r� - <br />Other Repairs: <br />City/State/Zip: <br />C ✓Gv., <br />Total Cost of S <br />Payment Method: ©-Check <br />❑ Cash <br />0 Credit <br />--4!v115 vl (�5S <br />Tank (check if present) <br />Tank leaks Zlow the <br />Tank leaks above the <br />Maintenance hole cover Is damaged, <br />cracked, unsecured, or appears to be <br />designed operating <br />depth <br />designed operating depth <br />structural) <br />unsound <br />eptic/holding Tank #1 <br />Gallons: f Z Ali <br />❑ Yes <br />� <br />❑ Yes � <br />❑ Yes <br />Q No <br />Septic/holding Tank #2 <br />❑Yes <br />Q40, <br />❑Yes ©No <br />❑Yes <br />No <br />Gallons: j 2 5-;,V <br />❑ Pretreatment Tank <br />Gallons: <br />❑ Yes <br />❑ No <br />❑ Yes ❑ No <br />❑ Yes <br />❑ No <br />Bump Tank <br />Gallons: / 2 $--V <br />❑ Yes <br />o <br />❑ Yes <br />❑ Yes <br />CVO <br />i <br />How Accessed: Maintenance Hole <br />Scum/Sludge Measured <br />Maintenanice, Holes Securely Replaced: <br />Reason For Pumping: <br />El Other (see attached) <br />rrYes//❑ No <br />1 Yes ❑ No <br />f✓l_°L •%,. 4— <br />old you identify any operational Issues or unsafe conditions while assessing the sewage tanks In this system, I.e., <br />_.-cracked tanks, missing baffles, broken ,mars, etc.? If so, explaln In commentSbelow. <br />Tank #1 ❑ Yes 6No <br />Tank #2 ❑ Yes ElAo <br />Pump Tank ❑ Yes o <br />System <br />❑ Structural integrity <br />❑ Structural integrity <br />❑ Structural integrity <br />ound <br />❑ Risers leaking <br />❑ Risers leaking <br />❑ Risers leaking <br />❑ Elevated drainfleld <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: <br />Disposal: 12JILand Application: ❑ Wastewater Treatment Plant <br />Disposal Site: j <br />Lime: <br />Gallons Z Y40 <br />Plowed: ❑ Yes R'No <br />Time: j d0" 7 <br />Temperature: c <br />pH: > 12 0— <br />Time: o <br />Temperature: `3. ;f� <br />pH: t > 12 E <br />