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Septic Service, LLC <br />1205 LaBeaux Ave NE <br />St. Michael, MN p55376 <br />DATE Q- Z !� <br />Maintenance Inspection Form <br />MP Lic. #L4286 <br />Maintainer Jim <br />Nick <br />0 Sam <br />• Phone: 763-497-2764 <br />• Email: duaneseptic@centurylink.net <br />INVOICE <br />Pumping Fee: <br />Name: <br />1l <br />j M <br />Long Pull Fee: <br />Address: 305-0 <br />n <br />1�— <br />Other Repairs: <br />City/State/Zip: <br />() ra <br />Payment Method: ❑ Check ❑ Cash <br />CkCredit <br />Total Cost of ServicE <br />the <br />Tank leaks above the <br />Maintenance hole cover is damaged, <br />Tan eck if pre <br />gne <br />opera ing depth <br />designed operating depth <br />cracked, unsecured, or appears to be <br />structural) <br />unsound <br />Septic/ oldi Tank #1 <br />❑ Yes <br />eNo <br />❑ Yes ❑�o <br />❑ Yes <br />elTo <br />Gallons: -op <br />peptic/holding Tank #2 <br />El Yes <br />, <br />C3�No <br />El Yes <br />El Yes <br />No <br />Gallons: j� <br />❑ Pretreatment Tank <br />Gallons: <br />❑ Yes <br />❑ No <br />❑ Yes ❑ No <br />❑ Yes <br />❑ No <br />imp Tank <br />eo <br />❑ <br />Gallons: <br />❑ Yes <br />E, " <br />❑ Yes .;;41 <br />Yes <br />o <br />How Accessed: IIAfaintenance Hole <br />Scum/Sludge Measued �� <br />Maintenance Holes Securely Replaced: <br />Reason F Pumping: <br />El Other (see attached) <br />❑ Yes ;�No <br />-1�11es ❑ No <br />Did you identify a" operational issues or unsafe conditions while assessing the sewage tanks in this system, i.e., <br />racked tanks, missing baffles, broken c etc.? If so, explain in comments_aei6-w— <br />Tank #1 ❑ Yes WrNo <br />Tank #2 ❑ Yes No <br />Pump Tank ❑ Yes DTlqo <br />System <br />❑ Structural integrity <br />❑ Structural integrity <br />❑ Structural integrity <br />ound <br />❑ Risers leaking <br />❑ Risers leaking <br />❑ Risers leaking <br />❑ Elevated drainfield <br />❑ Baffles <br />❑ Baffles <br />❑ Baffles <br />❑ Pressure bed <br />❑ Non -domestic waste <br />❑ Non -domestic waste <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 Plant <br />Disposal Site: <br />Lime: <br />Gallons <br />Plowed: ❑ Yes ❑ No <br />Time: <br />Temperature: <br />pH: > 12 ❑ <br />Time: <br />Temperature: <br />pH: > 12 ❑ <br />,✓�-�-�. �`'� sue. ,.�- �`'� .s�- <br />