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icher <br /> Maintenance Inspection Form <br /> MPot Lic. #L4286 <br /> Maintainer Zlim <br /> 0 Nick <br /> Service, LLC • Phone: 763-497-2764 <br /> sBeaux Ave NE <br /> iael, MN 55376� • Email: duaneseptic@centurylink.net <br /> 57,1..� }"I ,,/� INVOICE <br /> g Fee: / �3�•Jo 2��0 �"�(`J Name: IJ co,G(2 It i 0-Ut h.� <br /> ill Fee: 2� 2-i Address: 100,3 C©A- roe-0-1 pi_ <br /> epairs: City/State/Zip: <br /> Q CD,1b <br /> Est of Service: Payment Method: ❑ Check ❑ Cash ❑ Credit <br /> 4 Li(gls-D. <br /> Tank leaks below the Tank leaks above the Maintenance hole cover is damaged, <br /> nk(check if present) designed operating depth designed operating depth cracked,unsecured,or appears to be <br /> structurally unsound�nd <br />/holding Tank#1 ❑ Yes Er o ❑ Yes �1No ❑ Yes .B"No <br /> 1(511 <br />/holdip Tank#2 <br /> l 0 ❑ Yes Q No 0 Yes No 0 Yes 1r No <br /> atment Tank 0 Yes 0 No 0 Yes 0 No 0 Yes 0 No <br /> Tagk_,a„ 0 Yes 0 Yes to 0 Yes l2 No <br /> essed:C7Maintenance Hole Scum/Sludge Measured Maintenance Holes Securely Replaced: Reason Fo Pumping: <br /> ❑Other(see attached) 0 Yes 17 No g4s 0 No <br /> Did you identify a operational issues or unsafe conditions while assessing the sewage tanks in this system,I.e., <br /> cked tanks,missing baffles,broken s,etc.?If so, explain in comments-below. <br /> ❑ Yes No Tank#2 ❑ Yes - No Pump Tank 0 Yes - No System <br /> Structural integrity 0 Structural integrity 0 Structural integrity la"Pound <br /> Risers leaking 0 Risers leaking 0 Risers leaking 0 Elevated drainfield <br /> Raffles 0 Baffles 0 Baffles 0 Pressure bed <br /> Von-domestic waste ❑ Non-domestic waste 0 Electrical issues 0 Trenches <br /> ❑ Non-domestic waste 0 Ponding/Surfacing <br /> ❑ Effluent Filter/screen ❑ Other: <br /> Cleaned? ❑Yes 0 No <br /> its: <br /> Disposal: 0 Land Application: ❑WastewaterTreatment Plant jivp tie/IQ <br /> Site: Lime: Gallons Plowed: 0 Yes 0 No <br /> Temperature: pH: >12 0 <br /> Temperature: pH: >12 0 <br /> ,, Q.fi� THANKS! . , Me <br />