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Septic Service, LLC <br />1205 LaBeaux Ave NE <br />St. Michael, MN 55376 <br />DATE <br />Maintenance Inspection Form <br />MPCA Lic. #L4286 <br />Maintainer 0 Jim <br />*Nick <br />0 Sam <br />• Phone: 763-497-2764 <br />• Email: duaneseptic@centurylink.net <br />INVOICE <br />Pumping F <br />Name: <br />[[ <br />(�� IV <br />�� e� <br />Long Pull F <br />Address: •Z 2 / � <br />,f Sul (� <br />�. �i <br />. <br />� <br />Other Rep; <br />City/State/Zip: <br />Total Cost <br />— C-� <br />Payment Method: ❑ Check ❑ Cash <br />❑ Credit <br />N <br />AH <br />Tank leaks above the <br />Maintenance hole cover is damaged, <br />cracked, unsecured, or appears to be <br />Tank (check if present) <br />Tank leaks below the <br />designed operating depth <br />designed operating depth <br />structural) unsound <br />❑ ptic/holding Tank #1 <br />[I Yes Cyr <br />❑ Yes YIN o <br />El Yes <br />No <br />allons: Zoo <br />Septic/holding Tank #2 <br />� <br />El Yes ] Vo <br />❑Yes ClNo <br />El Yes <br />f� No <br />Gallons: ( S' <br />❑ Pretreatment Tank <br />Gallons: <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes <br />❑ No <br />ffi/Pump Tank <br />❑ Yes j�7' No <br />I] Yes No <br />El Yes <br />�o <br />Gallons: (Z �� <br />How Accessed: aintenance Hole <br />Scum/Sludge Measured <br />Maintenance Holes Securely Replaced: <br />Reason For Pumping: <br />❑ Other (see attached) <br />CYYes ❑ No <br />el'es ❑ No <br />Did you identify any operational issues or unsafe conditions while assessing the sewage tanks in this system, i.e., <br />ci;acked tanks, missing baffles, brokenyavers, etc.? If so, explain in commen'>,below. <br />Tank #1 ❑ Yes o <br />Tank #2 ❑ Yes No <br />Pump Tank ❑ Yes No <br />System <br />❑ Structural integrity <br />❑ Structural integrity <br />❑ Structural integrity <br />ound <br />❑ Risers leaking <br />❑ Risers leaking <br />❑ Risers leaking <br />❑ Elevated drainfield <br />❑ Baffles <br />❑ Baffles <br />❑ Baffles <br />❑ Pressure bed <br />❑ Non -domestic waste <br />❑ Non -domestic waste <br />❑ Electrical issues <br />❑ Trenches <br />❑ Non -domestic waste <br />❑ Ponding/Surfacing <br />❑ Effluent Filter/screen <br />❑ Other: <br />Cleaned? ❑ Yes ❑ No <br />Comments: <br />Disposal: ❑ Land Application: 2'fg/astewater Treatment Plant L.,� Ic✓-I41"' <br />Disposal Site: <br />Lime: <br />Gallons Z&,c <br />Plowed: ❑ Yes ❑ No <br />Time: <br />Temperature: <br />pH: > 12 ❑ <br />Time: <br />Temperature: <br />pH: > 12 ❑ <br />