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Property address: 2650 Fox Street <br />City: _Wayzata__ <br />State: MN <br />Parcel ID: 0411723410003 <br />Zip code: 55391 <br />5. Is the tank designed as a leaky tank? (Example: seepage pit, cesspool, drywell, leaching pit) <br />Tank #1: ❑ Yes ® No Verification method used: visual <br />Tank #2: ❑ Yes ® No Verification method used: <br />6. Is there evidence of the following? <br />Maintenance hole cover is <br />Tank leaks below the Tank leaks above the damaged, cracked, unsecured, or <br />Tank heck if present) ..igned o�eratin�depth designed operating depth _ - appears to be structurally unsound <br />_ _ <br />_ ® Septiclholding an #1 Yes ® No ❑ Yes No ❑ Yes No <br />Septictholding Tank #2 [] Yes 0 No _ ❑ Yes No � Yes No <br />Pretreatment Tank _(] Yes _� No ❑ Yes No Yes No <br />® Pump Tank -- - - [] Yes ® No - - ❑..Yes ® No ..___Q Yes _ 0-No <br />Describe detail for any "Yes" <br />7. How many gallons of seppage were removed? <br />Tank #1: 1300 _ Tank #2: _1300 Pretreatment Tank: Pump Tank:_750 <br />B. Where was the septage taken? ® Wastewater treatment facility ❑ Land application ❑ Other <br />Explanation (Facility name/Site #): Watertown <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 lid, electrical hazard, etc.) <br />Explanation: _ <br />10. List any troubleshooting and minor repairs completed or declined by owner: <br />❑ Troubleshooting and repairs conducted: 1 ❑ Repairs 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 of a Minnesota4censed SSTS Maintenance Business, in compliance <br />with Minnesota Rules Chapters 7080 - 7083: <br />❑ As a noncertified individual who has received proper training, daily worts review, and periodic observation, or <br />® As a designated certified individual of the business listed below. <br />Company information Employee information <br />Company name: Chip's Septic Services <br />Business license number: 2064 <br />Print name: Pemel Hentges <br />Certification number: (if applicable): 4761 <br />Email: chipseptioMgmail,com __._..._ _ Phone number: 952-200-3176 <br />Employee's signature: mm/dd Date ( IYYYY): 7/9/2025 <br />www.pca.state.mn.us • 651-296-6300 800-657-3864 • Use your preferred relay service Available in alternative formats <br />wq-wwists4-38 • 10122118 page 2 of 3 <br />