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Jim Eicher <br />Maintenance Inspection Form <br />MPCA Lic. #L4286 <br />Maintainer Jim <br />k�Vick <br />p o4 <br />= Sam <br />Septic Service, LLC <br />• Phone: 763-497-2764 <br />1205 LaBeaux Ave NE <br />St. Michael, MN 55376 <br />•Email: duaneseptic@centurylink.net <br />DATE —7 - °i - Z <br />INVOICE <br />_ <br />Pumping Fee: <br />Name: <br />`(' <br />D�3 <br />Long Pull Fee: <br />Address: 3ky 51`Ak Ret' <br />Other Repairs: <br />City/State/Zip: <br />Total Cost of SE <br />Payment Method: heck ❑ Cash ❑ Credit <br />Maintenance hole cover is damaged, <br />Tank (check <br />ink leaks below the <br />ueb7gned operating depth <br />Tank leaks above the cracked, unsecured, or appears to be <br />designed operating depth <br />structural) unsound <br />IT-Septic/holding Tank #1 <br />❑ Yes I to <br />❑ Yes ❑ No <br />2--Ves ❑ No <br />Gallons: Sx,97 <br />Septic/holding Tank #2 <br />El Yes C�"No <br />El Yes E�No <br />❑Yes (n N0 <br />Gallons: <br />E-,��t Tank 44 3 <br />❑ Yes C3' No <br />❑ Yes ❑ No <br />❑ Yes Er No <br />Gallons: t <br />❑ Pump Tank <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />Gallons: <br />How Accessed: Maintenance Hole <br />Scum/Sludge Measured <br />Maintenance Holes Securely Replaced: <br />Reason For Pumping: <br />❑ Other (see attached) <br />T <br />C-1'Yes ❑ No <br />Ds ❑ No <br />Did you identify any operational issues or unsafe conditions while assessing the sewage tanks In this system, i.e., <br />ai. '2 rFa ovniain in rnmments below. <br />Tank #1 ❑ Yes No <br />Tank #2 ❑ Yes o <br />Pump Tank ❑ Yes ❑ No <br />System <br />❑ Structural integrity <br />❑ Structural integrity <br />❑ Risers leaking <br />❑ Structural integrity <br />❑ Risers leaking <br />Mound <br />❑ Elevated drainfield <br />❑ Risers leaking <br />❑ Baffles <br />❑ Baffles <br />❑ Baffles <br />❑ Pressure bed <br />❑ Non -domestic waste <br />❑ Non -domestic waste <br />❑ Electrical issues <br />❑ Non -domestic waste <br />❑ Trenches <br />❑ Ponding/Surfacing <br />❑ Effluent Filter/screen <br />❑ Other: <br />Cleaned? ❑ Yes ❑ No <br />Comments: t Si E'� !{ ; U i AL W <br />C©vs/ bh <br />Disposal: <br />Disposal Site: Lime: <br />Time: <br />Time: <br />❑ Land Application: 2'Wastewater Treatment runt — <br />Gallons 36-s'o <br />w`� Plowed: ❑ Yes ❑ No <br />Temperature: pH: > 12 ❑ <br />Temperature: pH: > 12 ❑ <br />