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Septic Service, LLC <br />1205 LaBeaux Ave NE <br />St. Michael, MN 55376 <br />Maintenance Inspection Form <br />MPCA Lic. #L4286 <br />Maintainer Jim <br />Nick <br />0 Sam <br />• Phone: 763-497-2764 <br />• Email: duaneseptic@centurylink.net <br />INVOICE <br />LJMI L <br />Pumping Fee: <br />Name: - <br />Address: <br />Long Pull Fee: <br />Other Repairs: <br />City/State/Zip: <br />0 V-00 -o <br />Total Cost of SE <br />Payment Method: ❑ Check ❑ Cash <br />❑ Credit <br />VOL", <br />Maintenance hole cover is damaged, <br />Tank (check <br />ink leaks below the <br />gned operating depth <br />Tank leaks above the <br />designed operating depth <br />cracked, unsecured, or appears to be <br />structural) unsound <br />Septic/holding Tank #1 <br />❑ Yes E No <br />❑ Yes No <br />❑ Yes <br />Gallons: ( 2Z3'0 <br />ET-Septic/holding Tank #2 <br />❑ Yes n No <br />❑ Yes Ql<o <br />❑ Yes <br />Z NO <br />Gallons: <br />❑ Pretreatment Tank <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes <br />❑ No <br />Gallons: <br />2/pump Tank <br />El Yes Z No <br />El Yes 2--No <br />El Yes <br />,� <br />[7" No <br />Gallons: p J <br />How Accessed: aintenance Hole Scum/Sludge Measured Maintenance Holes Securely Replaced: Reason For Pumping: <br />❑ Other (see attached) UT -Yes ❑ No Q Yes El No <br />Did you identify any operational Issues or unsafe conditions while assessing the sewage tanks In th/s system, i.e., <br />_..11-- or, 7 Tr — a 1n in in rnmmPn N_hPlnw. <br />Tank #1 ❑ Yes No <br />Tank #2 ❑ Yes 2No <br />Pump Tank ❑ Yes No <br />System <br />❑ Structural integrity <br />❑ Structural integrity <br />❑ Structural integrity <br />ound <br />❑ Elevated drainfield <br />❑ Risers leaking <br />❑ Risers leaking <br />❑ Risers leaking <br />❑ Pressure bed <br />❑ Baffles <br />❑ Non -domestic waste <br />❑ Baffles <br />❑ Non -domestic waste <br />❑ Baffles <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: [?,Wastewater Treatment riant L rK- � � -- <br />Disposal Site: Lime: Gallons 3 6? Plowed: ❑ Yes ❑ No <br />Time: Temperature: pH: E]EE <br />2 ❑Time: Temperature: pH: 2 ❑ <br />