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Septic Service, LLC <br />1205 LaBeaux Ave NE <br />St. Michael, MN 55376 <br />DATE ' - ? 2 <br />Pumping Fee: <br />Lonq Pull Fee: <br />er <br />Total Cost of Servi <br />Maintenance Inspection Form <br />MPCA -ic. #L4286 <br />Maintainer Jim <br />Nick <br />0 Sam <br />• Phone: 763-497-2764 <br />• Email: duaneseptic@centurylink.net <br />INVOI <br />(f t Name: 'f f <br />Address: 4' <br />9() <br />City/State/Zip: / <br />/, �t , j7^�l s <br />Payment Method: ❑ Check ❑ Cash ❑ Credit <br />Maintenance hole cover is damaged, <br />�w the <br />Tank (check if pG_�a..T— - -- - <br />Tank leaks above the <br />cracked, unsecured, or appears to be <br />designed operating depth <br />designed operating depth <br />structural) unsound <br />eptic/holding Tank #1 <br />El Yes ❑ No <br />❑Yes ElNo <br />El Yes ElNo <br />Gallons: <br />;;i�eptic/holding Tank #2 <br />El Yes ❑ No <br />I--] Yes ElNo <br />El Yes ElNo <br />Gallons: <br />❑ Pretreatment Tank <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />Gallons: <br />❑ Pu ank <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />ons: <br />How Accessed: ❑ Maintenance Hole <br />Scum/Sludge Measured <br />Maintenance Holes Securely Replaced: <br />Reason For Pumping: <br />❑ Other (see attached) <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />AA in �ca,Pt <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.? If so, 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: ❑ Land Application: P"Wastewater Treatment Plant i-'& <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 ❑ <br />