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Septic Service, LLC <br />1205 LaBeaux Ave NE <br />St. Michael, MN 55376 <br />DATE <br />Pumping Fee: '- <br />Long Pull Fee: <br />Other Repair&.!:- - <br />Maintenance Inspection Form <br />MPQA Lic. #L4286 <br />Maintainer .0 Jim <br />Nick <br />0 Sam <br />• Phone: 763-497-2764 <br />• Email: duaneseptic@centurylink.net <br />INVOICE <br />Name: <br />Address: <br />City/State/Zip: ' <br />Payment Method. <br />❑ Check <br />❑ Cash <br />El Credit <br />Total Cost of ServiceZ 27— <br />-- �� <br />Maintenance hole cover is damaged, <br />Tank leaks below the <br />Tank leaks above the <br />cracked, unsecured, or appears to be <br />Tank (check if present) <br />designed operating depth <br />designed operating depth <br />structurally <br />unsound <br />❑ Septic/holding Tank #1 <br />❑ Yes ❑ No <br />❑ Yes <br />❑ No <br />❑ Yes <br />❑ ' No <br />Gallons: <br />D Septic/holding Tank #2 <br />❑ Yes - O No <br />❑ Yes <br />-Ij No <br />❑ Yes <br />-D' No <br />Gallons: <br />❑ Pretreatment Tank <br />❑ Yes ❑ No <br />❑ Yes <br />❑ No <br />❑ Yes <br />❑ No <br />Gallons: <br />Pump Tank <br />❑ Yes ❑ No <br />❑ Yes <br />0 No <br />❑ Yes <br />'_0 No <br />Gallons: <br />11 <br />=essed:0 Maintenance Hole Scum/Sludge Measured Maintenance Holes Securely Replaced: Reason For Pumping: <br />r <br />❑ Other (see attached) ❑ Yes - El -No El -Yes ❑ No <br />Did you identify any operational issues or unsafe conditions white assessing the sewage tanks in this system, i.e., <br />cracked tanks, missing baffles, broken covers, etc,? If so, explain in comments below. <br />#1 ❑ Yes ©No Tank #2 ❑ Yes ❑'No Pump Tank ❑ Yes a No System <br />❑ Structural integrity ' ❑ Structural integrity ❑ Structural integrity ED Mound <br />❑ Risers leaking ❑ Risers leaking ❑ Risers leakng El Elevated drainfield <br />❑ Raffles ❑ Baffles❑ Baffles ❑ Pressure bed <br />❑ Non -domestic waste ❑ Non -domestic waste ❑ Electrical issues El Trenches <br />❑ Nan -domestic waste ❑ PondinglSurfacing <br />❑ Effluent Filter/screen ❑ Other: <br />Cleaned? ❑ Yes ❑ No <br />Disposa4 Site: <br />Time: <br />Time: <br />Disposal: <br />Lime: <br />❑ Land Application: ❑ Wastewater Treatment Plant <br />Gallons <br />Temperature: <br />Temperature: <br />Plowed. ■ Yes ■ 110 <br />• f <br />