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Property address: 2125 Carriage Ln Parcel ID: 10-117 23-24-0037 <br />City: Orono State: MN Zip code: 55391 <br />S. is the tank designed as a leaky tank? (Example., seepage pit, c9opwi drywell, leaching pit) <br />Tank 411: ❑ Yes IFPNo Verification method used: <br />Tank #2: ❑ Yes ❑ No Verification method used: <br />6. <br />is uzere evraence oT une Torrowrng <br />Tank Ichack if resent <br />r <br />Tank teaks below the <br />designed operatina depth <br />Tank leaks above the <br />des) ned o radna depth <br />Maintenance hole cover is <br />damaged, cracked, unsecured, or <br />appears to be structurally unsound <br />Se tic/holdi Tank #1 <br />0 Yes <br />No <br />Yes Jallo <br />0 Yes No <br />Septic/holdingSeptkftlding Tank #2 <br />Yes <br />o <br />No <br />0 Yes <br />Yes KNo <br />No <br />0 Yes No <br />Yes No <br />Pretreatment Tank <br />Yes <br />El Pump Tank <br />0 Yes <br />QRNo <br />0 Yes &No <br />Yes No <br />Describe detail for any "Yes" <br />7. How many gallons of seepage were removed? <br />Tank #1: / 3 oo Tank #2: 1.104 Pretreatment Tank: Pump Tank: V ob <br />8. Where was the septage taken? F Wastewater treatment facility ❑ Land application ❑ Other <br />Explanation (Facility name/Site #). _ 1 der' *LVnI <br />9. Did you identify any operational issues or unsafe conditions while assessing the sewage tanks in this system? <br />❑ Yes &No If yes, identify tank and explain: <br />❑ Evidence of non -domestic waste ❑ Baffle(s) condition ❑ Effluent screen condition <br />❑ Maintenance hole and extensions condition ❑ Other conditions (e.g. structural Integrity of tank or lid, electrical hazard, etc.) <br />Explanation: <br />10. List any troubleshooting and minor repairs completed or declined by owner. <br />and reDairs conducted: <br />Additional comments or suggestions for owner's consideration: <br />Pumping record <br />! perjonally conducted the work described above on behalf of a Minnesota -licensed SSTS Maintenance Business, in compliance <br />with Minnesota Rules Chapters 7080 — 7083: <br />❑ As a noncertified individual who has received proper training, daily work review, and periodic observation, or <br />® As a designated certified individual of the business listed below. <br />By typing/signing my name below, I certify the above statements to be true and correct, to the best of my knowledge, and that <br />this information can be used for the purpose of processing this form. <br />Company information <br />Company name: Kothrade Sewer, Water $ Excavating, Inc <br />Business license number. MPCA 192 <br />Employee information <br />Print name: L.Bursch <br />Certification number: is spotc"y C9199 <br />Email: —infoOkothrade.com a number. 763-498-8702 <br />Employee's signature: Date (mm/dd/yyyy): <br />www.pca.state.mn.us • 651-2%-6300 • 800.657.3864 Use your preferred relay service • Available in alternative formats <br />wq-wwlsts4-38 • 4128/21 Pope 2 of 3 <br />