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Property address: 15 Stubbs Bay Rd. N. Parcel ID: <br />City: Orono State: MN. Zip code: 55359 <br />5. Is the tank designed as a leaky tank? (Example: seepage pit, cesspool, drywell, leaching pit) <br />Tank #1: ❑ Yes ® No Verification method used: Camera <br />Tank #2: ❑ Yes ® No Verification method used: Camera <br />6. Is there evidence of the following? <br />' Maintenance hole cover is <br />Tank leaks below the Tank leaks above the damaged, cracked, unsecured, or <br />Tank check if resent designed operating depth designed operating depth appears to be structurally unsound <br />® Septic/holding Septic/holdingTank #1 ❑Yes ® No ElYes ® No ElYes ® No <br />® <br />Septic/holding Septic/holdingTank #2 ElYes ® No ❑Yes ®No [:]Yes ®No <br />ElPretreatment Tank ❑ Yes [:]No ElYes ElNo ❑ Yes ElNo <br />®Pum Tank ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No <br />Describe detail for any "Yes" <br />7. How many gallons of septage were removed? <br />Tank #1: 1250 Tank #2: 1000 Pretreatment Tank: Pump Tank: 400 <br />8. Where was the septage taken? ® Wastewater treatment facility ❑ Land application ❑ Other <br />Explanation (Facility name/Site #): Blue Lake Treatment <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 />❑ Troubleshooting and repairs conducted: 1 ❑ Repairs declined by owner: <br />Additional comments or suggestions for owner's consideration: <br />Pumping record <br />/ 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 information <br />Company name: Mike's Septic and Mckinley Sewer <br />Business license number: 2899 <br />Email: mckinlevsewe(apmail.com <br />Employee's signature: Matt Mckinley <br />Employee information <br />Print name: Matt Mckinley <br />Certification number: (if applicable): 8067 <br />Phone number: 952-440-1800 <br />Date (mm/dd/yyyy): 3/12/2024 <br />www.pca,state,mn.us 651-296-6300 800-657-3864 Use your preferred relay service • Available in alternative formats <br />wq-wwists4-38 • 4/28/21 Page 2 of 3 <br />