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Septic Service, LLC <br />1205 LaBeaux Ave NE <br />St. Michael, MN 55376 <br />DATE 7 1 I(- z S <br />Pumping Fee: <br />Long Pull Fee: <br />Other Repairs: <br />Total Cost of Servi, <br />Maintenance Inspection Form <br />MPCA Lic. #L4286 <br />Maintainer Jim <br />Nick <br />= Sam <br />• Phone: 763-497-2764 <br />• Email: duanesepticCcenturylink.net <br />INVOICE <br />Name:,�`�� ai© ek �lLuC, <br />Address: <br />City/State/Zip: <br />Uo,w <br />Payment Method: ❑ Check ❑ Cash ❑ Credit <br />y� <br />Maintenance hole cover is damaged, <br />-aks below the Tank leaks above the cracked, unsecured, or appears to be <br />Tank (check if pr gned operating depth designed operating depth <br />� structural) unsound <br />eptic/holding Tank #1 ❑ Yes No ❑ Yes CfiNo ❑ Yes No <br />Gallons: ( <br />❑ Septic/holding Tank #2 ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br />Gallons: <br />❑ Pretreatment Tank ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br />Gallons: <br />❑ Pump Tank ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br />Gallons: <br />How Accessed: aintenance Hole Scum/Sludge Meas�ur d Maintenance Holes Securely Replaced: Reason For Pumping: <br />❑ Other (see attached) ❑Yes ❑ No C� Yes ❑ No �"` �� <br />Did you identify any operational issues or unsafe conditions whiie assessing the sewage tanks in this system, i.e., <br />cked tanks, missing baffles, broken covers, etc.? If so, explain in comments below. <br />Tank #1 ❑ Yes o Tank #2 ❑ Yes ❑ No Pump Tank ❑ Yes ❑ No System <br />❑ Structural integrity ❑ Structural integrity ❑ Structural integrity ❑ Mound <br />El Risers leaking g ❑ Risers leaking ElRisers leaking ❑ Elevated drainfield ❑ Baffles ❑Baffles El Baffles ❑ Pressure bed <br />❑ Non -domestic waste ❑ Non -domestic waste ❑ Electrical issues ❑ Trenches <br />❑ Non -domestic waste ❑ Ping/Surfacing <br />❑ Effluent Filter/screen Er9t er f� <br />Cleaned? ❑ Yes ❑ No <br />Comments: n �, r v .�— kt <br />N <br />Disposal: C�Land Application: ❑Wastewater Treatment Plant <br />Disposal Site: �� <br />Lime: Gallons 1� Plowed: El Yes No <br />Temperature: q,'? pH: iZ- Z- > 12 � <br />Time: 3 D 3 L > 12 <br />Time: 3Y Temperature: -2_Q. y pH: 2' <br />a <br />O -f ► <br />