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MN MPCA <br />INDIVIDUAL SEWAGE TREATMENT SYSTEM (ISTS) PUMPING RECOn <br />Owner Address <br />Pumper <br />No. of Tanks Pumped Total Gallons Pumped <br />Check all that apply: qResidential LJ commercial L]Rental <br />'* Septic LJ Holding gPump Chamber LJ Cesspool Ll Abandoned Ll Other: <br />Condition of Baffles (baffles must be inspected) *Acceptable LJ Unacceptable LIReplaced Baffles <br />Reason for pumping? <br />Disposal Location (be specific) <br />Water tight tank? KYes Ll No <br />Any tank leakage below or above the operating depth? Ll Yes No <br />Pumped From: �Maintenance Hole El Removed Tank Lid (stave, for example) 0 Inspection Pipe (see below) <br />I have been informed about the correct tank cleaning procedures and understand that I risk having my system fail prematurely if the tank is not <br />pumped through the Maintenance Hole/ Tank lid to enable the removal of solids. <br />Signature of Owner/ Owner's Agent <br />Safety Concerns / Repairs <br />Pumper/ Inspector Signature <br />Reason for not pumping through the Maintenance -Hole /Tank Lid <br />Date <br />Only one permit is needed per ISTS. if there is more than one ISTS on a property, submit a separate permit for each ISTS. Submit a permit whenever <br />a tank is pumped for abandonment. Pumping the tank does not constitute a compliance inspection, <br />cz <br />cc <br />LO <br />