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Septic Service, LLC <br />1205 LaBeaux Ave NE <br />St. Michael, MN 55376 <br />DATE % ( 104� <br />Maintenance Inspection Form <br />MPCA Lic. #L4286 <br />Maintainer Jim <br />0 Nick <br />0 Sam <br />® Phone: 763-497-2764 <br />® Email: du anesepticCcenturylink.net <br />INVOICE <br />Pumping I <br />Name: (? <br />Long Pull <br />Address: Ll <br />U <br />Other Rer <br />City/State/Zip: <br />b 'f°�`� <br />Total Cosi <br />\ <br />Payment Method: ❑ Check ❑ Cash ❑ 'Credit <br />Tank leaks above the <br />Maintenance hole cover is damaged, <br />< leaks below the <br />Tank <br />operating <br />depth <br />designed operating depth <br />cracked, unsecured, or appears to be <br />structural) unsound <br />RI/Se Tank #1 <br />❑ Yes <br />12-IN o <br />❑ Yes No <br />❑ Yes r<No <br />Gallons: <br />Z"Septic/holding Tank #2 <br />❑Yes <br />l; No <br />❑ Yes ❑�fVo <br />❑ Yes B'' <br />Gallons: <br />O <br />❑ Pretreatment Tank <br />Gallons: <br />r <br />❑ Yes <br />❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />Pump Tank <br />El Yes <br />No <br />,� <br />El �No <br />❑Yes <br />Gallons: <br />9Ao <br />ssed:❑ Maintenance Hole <br />r!�!! <br />Scum/Sludge Measured <br />Maintenance Holes Securely Replaced: <br />Reason For Pumping: <br />❑ Other (see attached) <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />Did you identify any operational issues or unsafe conditions while assessing the sewage tanks in this system, i.e., <br />cracked tanks, missing baffles, broken covers, etc.? Ifso, explain in comments below. <br />Tank #1 ❑ Yes ❑ No <br />Tank #2 ❑ Yes ❑ No <br />Pump Tank ❑ Yes ❑ No <br />System <br />❑ Structural integrity <br />❑ Structural integrity <br />❑ Structural integrity <br />❑ Mound <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: -0- Land Application: ❑ Wastewater Treatment Plant <br />Disposal Site: \'\' <br />Lime: i <br />Gallons ;; %`` ' <br />Plowed: ❑ Yes ❑ No <br />Time: <br />Temperature: <br />pH: j ; > 12 ❑ <br />Time: n <br />Temperature: <br />pH: > 12 0 <br />