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Jirr <br />Maintenance Inspection Form <br />MPCA Lic. #L4286 <br />SeF. <br />1205 L, <br />St. Michas <br />DATE S <br />Maintainer 0 Jim <br />J�,-N <br />0 Sam <br />• Phone: 763-497-2764 <br />• Email: duaneseptic@centurylink.net <br />INVOICE <br />Pumping Fee. <br />Name: <br />Address: -2 r ; <br />Cc� `5 � �=Cj <br />Long Pull Fee: <br />- . L «� � c <br />V_ <br />City/State/Zip: <br />Other Repairs: <br />0 <br />Total Cost of Se <br />��t�vnr <br />Payment Method: ❑ Check ❑ Cash <br />❑ Credit <br />Tank leaks above the <br />Maintenance hole cover is damaged, <br />oelow the <br />Tank (check--,,- _ <br />____ <br />esign ating depth <br />designed operating depth <br />cracked, unsecured, or appears to be <br />structural) unsound <br />Septic/holding Tank #1 <br />Gallons: 2j <br />El Yes <br />El Yes C �10 <br />El Yes <br />No <br />Septic/holding Tank #2 <br />ElYes KINo <br />ElYes No <br />❑ Yes <br />Gallons: L 3 y:,, <br />❑ Pretreatment Tank <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes <br />❑ No <br />--Gallons: <br />GI'ump Tank <br />'Co <br />❑ <br />El Yes <br />C�"No <br />Gallons: (� <br />El Yes 2' <br />Yes No <br />- <br />M <br />How Accessed: ETMaintenance Hole <br />Scum/Sludge Measured <br />Maintenance Holes Securely Replaced: <br />Reason For Pumping: <br />❑ Other (see attached) <br />M-Yes El No <br />e Yes ❑ No <br />6. `4 <br />Did you identify any operational issues or unsafe conditions while assessing the sewage tanks in this system, i.e., <br />Spcked tanks, missing baffles, broken fivers, etc.? If so, explain in comment low. <br />Tank #1 ❑ Yes Ugo <br />Tank #2 ❑ Yes o <br />Pump Tank ❑ Yes ❑ o <br />System <br />❑ Structural integrity <br />❑ Structural integrity <br />❑ Structural integrity <br />2Mound <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: ❑ Land Application: 1?1lastewater Treatment Plant <br />Disposal Site: <br />Lime: <br />Gallons 7 700 <br />Plowed: ❑ Yes ❑ No <br />Time: <br />Temperature: <br />pH: > 12 ❑ <br />Time: <br />Temperature: <br />pH: > 12 ❑ <br />'-�.-•z cam' � � .� • �. •-9�.� C�r'� �. <br />s�.- <br />