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Date: <br />Otivner: r �Zr'c��t <br />Property address: <br />for Pumping: <br />��UndDt}!On Uf tams: <br />filter cleaned: Yes <br />No <br />nl <br />ank leafage observed: <br />gallons removed: <br />#I) #�U <br />�Safefy cozlcei•ns: <br />f <br />Il�ecorramencied t•epairs: <br />ICommer�ts: <br />Phone#• j 7. 4 d <br />Owners address: (if different) <br />'I'anlc Information <br />❑ compliance inspection CI <br />i--•f""anholes C? <br />holding tank C�-�•tflaintenance <br />inspection pipe (holding tanks only) <br />{owner signature req'd if refusing to allow pumping through maintenomce hole) <br />baffles good: <br />0 <br />n/a <br />above operating depth: <br />alarm worlClllg: es <br />io <br />n/a <br />Yes o� (repairs recommended) <br />below operating depth; ) <br />#3 #4 pump tank !(fKl a total r�C: <br />Yes r (failing to protect groundwater <br />municipal C� location: � � �� <br />Land apply ❑ <br />location: <br />1 hereby cer•tr'fy that !have completed this work in accordance with r19Rr 7083. D77D and a»y local re�l:eirernerztr. <br />No deter•rnination or grcarantee off rtrcr-e system per;�orma»ce has been nor can be made. <br />Chip's Semitic Service, LLC, SSTS License <br />Maintainer signature 16762 Babcock Avenue #2064 <br />Lester Prairie, MN. 55354 <br />(952) 2M3176 <br />