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Septic Tank Pumping/Maintenance <br />Owner Information <br />Date: <br />Z zZS <br />/ Z( <br />Phone: <br />7 (.3 <br />— Z Z S — <br />Owner: <br />fA A x, <br />Sa 1,j U G k <br />Email: 014VWA; <br />� <br />, S14LuL1L <br />Plg9 MIMI I Owner's Address (if different <br />Orate o /YMis) S-3Z <br />Tank Information <br />v <br />Reason for Pumping: ❑ Complinace Inspection ❑ Holding Tank (]l-A4aintenance <br />Method of Access: Q'1Gl-anholes ❑ Inspection Pipe (holding tanks only) <br />(Owner's signature req'd if refusing to allow pumping through maintenance hole) <br />Condition of Tanks: <br />Filter Cleaned Yes Baffles good: Kp Alarm working: <br />No No No <br />N/A N/A <br />Tank Leakage Observed: Above operating depth Yes Io(repairs recommended) <br />Below operting depth Yes/lya�(failing to protect groundwater) <br />Gallons Removed: ((``�� <br />#1 /00U #2 /()Ou #3 #4 Pump tank _5 6(J Total Z50'u <br />Disposal Method: Municipal: Q Location: Watertown Wastewater Facility <br />Land Applied: ❑ Location: <br />Safety Concerns: <br />Recommended Repairs: 101104 le — <br />Comments: <br />a� <br />I hereby certify that 1 have completed this work in accordance with MN 7083.0770 and any local requirements. <br />No determination or guarantee offuture em per om as been nor can be made. <br />Chip's Septic Service, LLC & SSTS <br />Swartzer's Sewer Services License <br />16762 Babcock Avenue MA to aner Signature #2064 <br />Lester Prairie, MN. 55354 <br />(952) 200-3176 <br />chipseptic(c-)t;mail.com <br />