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D <br />Septic Service, LLC <br />1205 LaBeaux Ave NE <br />St. Michael, MN 55376 <br />DATE <br />Nick <br />C] Sam <br />® Phone: 763-497-2764 <br />CU41 ,�� ��44% / ®Email: duaneseptic@centurylink.net <br />INVOICE <br />Pumping Fee, <br />Name: _._- _ <br />Long Pull Fee: <br />Address: <br />Other Repairs: <br />City/State/Zip: <br />e; <br />G �.-s-f i. �.-CJ o ,. <br />U>b • LZ� <br />Total Cost of Serviced <br />�' ( is <br />Payment Method: Check <br />❑Cash <br />❑ Credit <br />_! <br />�t E.\ <br />yaU <br />Maintenance hole cover is damaged, <br />Tank (check if present) �i <br />Tank leaks <br />below the <br />Tank leaks above the <br />cracked, unsecured, <br />or appears to be <br />designed operating depth <br />designed operating depth <br />structural) unsound <br />g�Septic/holding Tank #1 <br />❑ Yes <br />❑- No <br />❑ Yes ErNo <br />❑ Yes <br />❑`TVo <br />Gallons:iPoo v <br />© Septic/holding Tank #2 <br />� <br />j <br />El No <br />❑Yes <br />❑� No <br />❑Yes o <br />❑Yes <br />Gallons: i o u <br />❑ Pretreatment Tank <br />❑ Yes <br />❑ No <br />❑ Yes ❑ No <br />❑ Yes <br />❑ No <br />Gallons: <br />❑ Pump Tank <br />❑ Yes <br />❑ No <br />❑ Yes ❑ No <br />❑ Yes <br />❑ No <br />Gallons. <br />How Accessed:J�Mintenance Hole <br />Scum/Sludge Measured <br />Maintenance Holes Securely Replaced: <br />Reason For Pumping: <br />❑ Other (see attached) <br />UYes ❑ No <br />1301 es ❑ No <br />Old you identify any operational issues or unsafe conditions <br />while <br />assessing the <br />sewage tanks In this system, i.e., <br />rcracked tanks, missing baffles, broken covers, <br />etc.? <br />Ifso, explain <br />in comments below. <br />Tank #1 <br />❑Yes 12`No <br />Tank #2 ❑Yes ©' o <br />Pump Tank ❑Yes ❑ No <br />System <br />❑ <br />Structural integrity <br />❑ <br />Structural integrity <br />❑Structural integrity <br />❑Mound <br />❑ <br />Risers leaking <br />❑ <br />Risers leaking <br />❑ Risers leaking <br />❑ Elevated drainfield <br />❑ <br />Baffles <br />❑ <br />Baffles <br />❑ Baffles <br />❑ Pressure bed <br />❑ <br />Non -domestic waste <br />❑ <br />Non -domestic waste <br />❑ Electrical issues <br />O•'T enches <br />❑ Non -domestic waste <br />❑ Ponding/Surfacing <br />❑ Effluent Filter/screen <br />❑ Other: <br />Cleaned? ❑ Yes ❑ No <br />Comments. <br />Disposal: ❑Land Application: ❑Wastewater Treatment Plant <br />Disposal Site: <br />Lime: <br />Gallons <br />Plowed: ❑Yes ❑ No <br />Time: <br />Temperature: <br />pH: > 12 ❑ <br />Time: <br />Temperature: <br />pH: > 12 0 <br />