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❑ Wastewater Treatment Plant <br />Disposal: [I Land Application: Plowed: El Yes <br />❑ No <br />Lime: Gallons > 12 ❑ <br />pH: <br />Temperature: > 12 ❑ <br />Temperature: <br />PH: <br />Jim Eicher <br />1, <br />D ° <br />Septic Service, LLC <br />1205 LaBeaux Ave NE <br />St. Michael, MN 55376 <br />DATE <br />Pumping Fee: <br />_ong Pull Fee: <br />Other Repairs <br />Total Cost of <br />Tank (check if present) <br />Septic/holding Tank #1 <br />Gallons: j b.5�' <br />cantle/holdina Tank #2 <br />I <br />Tank leaks below the <br />designed operating depth <br />❑ Yes No <br />❑ Yes ❑ o <br />Maintenance Inspection Form <br />MPA Lic. #L4286 <br />Maintainer zim" <br />0 Nick <br />Sam <br />• Phone: 763-497-2764 <br />• Email: duaneseptic@centurylink.net <br />slame: 0"r- <br />%ddress: f zou t C;VV,C r <br />,,ity/State/Zip: <br />�fJ 6�t <br />Payment Method: ❑ Check <br />Tank leaks above the <br />designed operating depth <br />El Yes �° <br />❑ Yes P-N-o <br />NVOICE <br />t& <br />❑ CaCa hs Cl Credit <br />Maintenance hole cover is damaged, <br />cracked, unsecured, or appears to be <br />�triinturaliv unsound <br />❑ Yes <br />❑ Yes <br />Gallons: i y) U <br />❑ Yes ❑ No ❑ Yes <br />❑ Pretreatment Tank ❑ Yes ❑ No <br />Gallons: <br />PAPP'Ump Tank J ❑ Yes o <br />❑ Yes o El Yes <br />cl <br />No <br />❑ No <br />Gallons. ix- J <br />nr!: <br />intenance Hole Scum/Sludge Measured Maintenance Holes Secur❑ No placed: �Fo� Pumping: <br />her (see attached) ❑ Yes <br />CXF10 es <br />in this <br />Did you identify any operational <br />issue <br />bs or unsafe affles, broken n�'t'ers, etc ons if if so assessing <br />incommwage entssbelow. system, i.e., <br />rac o System <br />No Tank #2 ❑ Yes o Pump Tank ❑ Yes ound <br />Tank #1 Lies <br />❑Structural integrity <br />❑Structural mtegnty <br />❑Elevated drainfield <br />❑ Structural integrity <br />❑ Risers leaking <br />❑Risers leaking <br />❑ Pressure bed <br />❑ Risers leaking <br />❑ Baffles <br />❑Baffles <br />❑Non -domestic waste <br />❑ Baffles <br />❑ Electrical issues <br />❑Trenches <br />El Ponding/Surfacing <br />❑ Non -domestic waste <br />❑ Non -domestic waste <br />❑Other: <br />❑ Effluent Filter/screen <br />Cleaned? ❑ Yes ❑ No <br />Disposal Site: <br />Time: <br />------ <br />Time: <br />__ <br />