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rroperty address:i Wrrchard r1ark Rd <br />Orono State: MN <br />is e tanK designed as a leaky tank r (Example: seepage pit, <br />Tank #1: 0 Yes VfNo Verification method used: <br />Tank 92: ■ Yes ■ No Verification method used: <br />6. Is there evidence of the following? <br />teaching pit) <br />11 <br />code: 55356 <br />Tank check if resent <br />Tank leaks below the <br />designed operating depth <br />Tank leaks above the <br />designed operating depth <br />Maintenance hole cover Is <br />damaged, cracked, unsecured, or <br />appears to be strut urall unsound <br />❑ <br />Septic/holdingSeptic/holding <br />Tank #1 <br />❑ <br />Yes <br />o <br />❑ <br />Yes <br />&2 No <br />❑ Yes <br />ftNo <br />❑ <br />Septic/holdingSeptic/holding <br />Tank #2 <br />❑ <br />Yes tR <br />No <br />Q <br />Yes <br />E Wo <br />❑ Yes <br />No <br />❑ <br />Pretreatment Tank <br />❑ <br />Yes ❑ <br />No <br />❑ <br />Yes <br />No <br />El <br />Yes <br />❑ No <br />❑ <br />Pump Tank <br />❑ <br />Yes <br />No <br />❑ <br />Yes <br />No <br />El <br />Yes <br />PNo <br />Describe detail for any "Yes" <br />7. How many gallons of septage were removed? <br />Tank #1: 1300 Tank #2: ! 34iJ Pretreatment Tank: Pump Tank: a2(V <br />8. Where was the septage taken? Waste ater 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 YNo 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: ❑ Repairs declined by owner. <br />Additional comments or suggestions for owner's consideration: <br />Pumping record <br />! personally conducted the work described above on behalf of aMinnesota-licensed SSTS Maintenance Business, in compliance <br />with Minnesota Rules Chapters 7080 — 7083: <br />❑ As a noncertifled individual who has received proper training, daily work review, and periodic observation, or <br />® As a designated certified individual of the business listed 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 & Excavating, Inc Print name: Larry Bursch <br />Business license number: MPCA 192 Certification number: (1rapplicable): C9199 <br />Email: info@kolhrac <br />Employee's signature: <br />Phone number: 763-498-8702 <br />Date (mm/dd/yyyy): 07 <br />www.pca.state.mn.us <br />wq-wwist5438 • 4/28/11 <br />651-296-6300 800-657-3864 • Use your preferred relay service Available in alternative formats <br />Page 2 of 3 <br />