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Property address: 705.Old Long Lake Rd Parcel ID: 38-118-23-32-0008 <br />City. Orono State: MN Zip code: 55391 <br />G. Is the tank designed as a leaky tank? (Example: seepage pit, cess col, dlywell, leaching pit) <br />Tank #1: ❑ Yes &No Verification method used: <br />Tank #2: ❑ Yes ❑ No Verification method used: <br />6. Is there evidence of the following? <br />Tank Icheck ifpresent) <br />Tank leaks below the <br />designed operatInA denth <br />Tank leaks above the <br />designed opetatInR depth <br />Maintenance hate cover is <br />damaged, cracked, unsecured, or <br />appears to be structure unsound <br />Sepickolding Tank #1 <br />0 Yes M&NO <br />Q Yes RNO <br />Q Yes RNO <br />S d(rAcidin Yank #2 <br />Yes MNo <br />0 Yes tfto <br />El Yes ONO <br />Pretreatment Tank <br />Yes No <br />Q Yes D No <br />Q Yes No <br />Pump Tank <br />Yes No <br />Q Yes 2 No <br />0 Yes No <br />Describe detall for any 'Yes" <br />7. Now many gallons of septage were removed? <br />Tank #1: 00 Tank #2: Pretreatment Tank: Pump Tank: 02AQ <br />8. Where was the seepage taken?�l Wastewater treatment facility ❑ Land application ❑ Other <br />Explanation (Facility name/Site #): <br />9. Did you Identify any operational Issues or unsafe conditions while assessing the sewage tanks In this system? <br />❑ Yes �?No If yes, Identify tank and explain: <br />❑ Evidence of non -domestic waste ❑ Baffle(s) condition ❑ Effluent screen condition <br />❑ Maintenance hole and extensions condition ❑ Other conditions (e.g. structural integrity of tank or tld, electrical hazard, etc.) <br />Explanation: <br />10. List any troubleshooting and minor repairs completed or declined by owner: <br />Additional comments or suggestions for owner's consideration: <br />Pumping record <br />I personally conducted the work described above on behalf ofa Minnesota -licensed SSTS Maintenance Business, in compliance <br />with Minnesota Rules Chapters 7080 — 7083: <br />❑ As a noncerftfed individual who has received proper training, daily work review, and periodic observation, or <br />® As a designated certified Individual of the business fisted below. <br />By typing/signing my name below. I certify the above statements to be true and correct, to the best of my knowledge, and that <br />this information can be used for the purpose of processing this form. <br />Company information Employee information <br />Company name: Kothrade Sewer, Water 8 Excavating, Inc Print name: Larry Bursch _ <br />Business license number. MPCA 192 Certification number: gagpticabre): C9199 <br />Email: inf kothrade.com Phone number: 783-498-8702 <br />Employee's signature: Date (mmlddfyyyy): <br />www.prastate.rnn,us 651-296-6300 • 800-U7-11M Useyour preferred relay service • Available In alternative formats <br />wq•wwistt4.38 • 4j2&21 Page 2of3 <br />