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Property address: 425 Ferndale Rd N Parcel ID: 36-118-23-14-0014 <br />City: Orono State: MN Zip code: 55391 <br />S. Is the tank designed as a leaky tank? (Example: seepage pit, ces 1, drywall, leaching pit) <br />Tank #1: ❑ Yes Verification method used: <br />Tank #2: ❑ Yes 6 No Verification method used: <br />6. <br />Is mere evlaence or me Tarowing-r <br />Tank check If resent <br />Tank leaks below the <br />des! ned opomtlna de <br />Tank leaks above the <br />desi ned o mtIng depth <br />Maintenance hole cover Is <br />damaged, cracked, unsecured, or <br />appears to be structurally unsound <br />Septic/holding Tank #1 <br />Yes o <br />0 Yes o <br />Yes No <br />Lclholdlng Tank #2 <br />❑ Se b <br />0 Yes No <br />o <br />YesFNo <br />Yes o <br />Pretreatment Tank <br />Yes No <br />Yes <br />D Yes No <br />Pump Tank <br />D Yes EWNo <br />0 Yes &rNo <br />Q Yes RNo <br />Describe detail for any "Yes" <br />7. How many gallons of septage were removed? <br />Tank #1: 1t66& Tank #2: /eoa Pretreatment Tank: Pump Tank: <br />8. Where was the septage taken?)KI Wastewater treatment facility ❑ Land application ❑ Other <br />Explanation (Facility name/She #): 1A.1-r , V,8j <br />9. Did you identify any operational issues or unsafe conditions while assessing the sewage tanks in this system? <br />❑ Yes PNo 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 IW, ekKMcal hazard, etc.) <br />Explanation: <br />10. List any troubleshooting and minor repairs completed or declined by owner: <br />Additional comments or suggestions for owner's consideration: <br />Pumping record <br />l personally conducted the work described above on behahi of a Minnesota -licensed SSTS Maintenance Busyness, in compliance <br />with Minnesota Rules Chapters 7080 — 7083: <br />❑ As a noncertifled 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(sfgning 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 />Employee information <br />Company name: Kothrade Sewer, Water & Excavating, Inc Print name: Larry Bursch <br />Business license number. MPCA 192 Certification number. (if applicable): C9199 <br />Email: —infoi2kothrade.com Phone number: 763-498-8702 <br />Employee's signature: Date (mmldd)Wyy): <br />www.pca.state.mn.us 651-286-6300 800-657-3M Use your preferred relay service Available in alternative formats <br />"-wwlsts4-38 • 412 121 Page 2 of 3 <br />