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Property address: 2650 Fox Street <br />City: Wayzata 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 />_Tank check if resent --designed <br />Tank leaks below the <br />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 structural) unsound <br />® Se tic/holdin Tank #1 <br />❑Yes <br />®No <br />❑Yes <br />®No <br />❑ Yes ® No <br />❑ Septic/holding Tank #2 <br />❑ Yes <br />® No <br />❑ Yes <br />® No <br />❑ Yes ® No <br />❑ Pretreatment Tank <br />❑ Yes <br />❑ No <br />❑ Yes <br />❑ No <br />El Yes [:]No <br />® Pump Tank <br />❑ Yes <br />® No <br />❑ Yes <br />® No <br />❑ Yes ® No <br />Describe detail for any "Yes" <br />7. How many gallons of septage were removed? r %k.- In �t-- <br />Tank #1: 1300 Tank #2: 1300 Pretreatment Tank: Pump Tank: 750 <br />8. 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: I ❑ 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 Minnesota -licensed SSTS Maintenance Business, in compliance <br />with Minnesota Rules Chapters 7080 — 7083: <br />❑ As a noncertified 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 />Company information Employee information <br />Company name: Chip's Septic Services <br />Business license number: 2064 <br />Email <br />Employee's signature: <br />.com <br />Print name: Pernel Hentges <br />Certification number: (if applicable): 4761 <br />Phone number: 952-200-3176 <br />Date (mm/dd/yyyy): 7/9/2025 <br />www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • Use your preferred relay service 0 Available in alternative formats <br />wq-wwists4-38 • 10112118 Page 2 of 3 <br />