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Septic Service, LLC <br />1205 LaBeaux Ave NE <br />St. Michael, MN 55376 <br />DATE 'Ij`=5 <br />Pumping FeE <br />Long Pull Fe <br />Other Repair <br />Total Cost of <br />Maintenance Inspection Form <br />MPCA Lic. #L4286 <br />Maintainer 0 Jim <br />Nick <br />Sam <br />® Phone: 763-497-2764 <br />® Email: duanesepticCcenturylink.net <br />INVOICE <br />Name: <br />Address: <br />City/State/Zip: <br />Na II/ Payment Method: heck ❑ Cash ❑ Credit <br />k/0 w <br />Tank (cP�aks below the <br />Tank leaks above the <br />Maintenance hole cover is damaged, <br />�—d <br />esea <br />i'gnoperating depth <br />designed operating depth <br />crackedunsecured, or appears to be <br />, <br />structural) unsound <br />Septic/holding Tank #1 <br />Gallons: (sue <br />El ©� <br />ElB' Yes "I10 <br />❑ Yes No <br />2rS-eptic/holding Tank #2 <br />Gallons: <br />El Yes 2_<0 <br />❑ Yes to <br />❑ Yes <br />❑ Pretreatment Tank <br />Gallons: <br />❑ Yes El No <br />❑ Yes El No <br />El Yes El No <br />2rmp <br />❑Yes 2 <br />Gallons: <br />Gallons: �� <br />No <br />❑ Yes S4. o <br />❑ Yes �o <br />How Accessed aintenance Hole <br />Scum/Sludge Measured <br />Maintenance Holes Securely Replaced: <br />Reason For Pumping: <br />❑ Other (see attached)F <br />B'Yes ❑ No <br />L�'Yes ❑ No <br />Did you identify any operational issues or unsafe conditions while assessing the sewage tanks'n this system, i.e., <br />-,Cracked tanks. missino baffles_ hrnkpn v lKvpnz atr_7 If anarnlain in—mmontf halm-, <br />Tank #1 ❑ Yes Rf No <br />Tank #2 ❑ Yes YNo <br />Pump Tank ❑ Yes No <br />System <br />❑ Structural integrity <br />❑ Structural integrity <br />❑ Structural integrity <br />ound <br />❑ Risers leaking <br />❑ Risers leaking <br />❑ Risers leaking <br />❑ Elevated drainfield <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: Viand Application: ❑ Wastewater Treatment Plant <br />Disposal Site: lJ 1 <br />Lime: <br />Gallon <br />Plowed: <br />❑ Yes <br />M"N—o <br />Time: <br />1 Z,-, _7 <br />Temperature: f a'j <br />pH: <br />( - Z <br />> 12 2r" <br />Time: <br />Z 3 7 <br />Temperature: 1 . °7 <br />pH: <br />Z <br />> 12 <br />