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Septic Service, LLC <br />1205 LaBeaux Ave NE <br />St. Michael, MN 55376 <br />Maintenance Inspection Form <br />MPCA Lic. #L4286 <br />Maintainer Zjim <br />= Nick <br />0 Sam <br />• Phone: 763-497-2764 <br />• Email: duaneseptic@centurylink.net <br />INVOICE <br />Pumping Fee: ----------- <br />-- Ova t <br />Name: <br />S30%, <br />— <br />Address:��,,.'T'r�Yy� <br />Long Pull Fee: <br />Other Repairs: <br />City/State/Zip: <br />Total Cost of Service: <br />Payment Method: ❑ Check ❑ Cash ❑ Credit <br />Maintenance hole cover is damaged, <br />Tank (check if present) <br />Tank leaks below the <br />Tank leaks above the <br />cracked, unsecured, or appears to be <br />designed operating depth <br />designed operating depth <br />structurally unsound <br />❑ Septic/holding Tank #1 <br />El Yes ❑ No <br />❑Yes ❑ No <br />El Yes ❑ No <br />Gallons: <br />❑ Septic/holding Tank #2 <br />El Yes El No <br />❑Yes El No <br />El Yes El No <br />Gallons: <br />❑ Pretreatment Tank <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />Gallons: <br />ePump Tank <br />�-- <br />Gallons: - a�J <br />❑ Yes ❑,flo' <br />❑ Yes D-No <br />❑ Yes 9`l o <br />How Accessed aintenance Hole <br />Scum/Sludge Measured <br />Maintenance Holes Securely Replaced: <br />Reason For Pumping: <br />El Other (see attached) <br />— <br />ElNo Yes 2 <br />Y❑ es ❑ No <br />bq-cIG N <br />Did you identify any operational issues or unsafe conditions while assessing the sewage tanks in this system, i.e., <br />rrarkerl ranks- missing baffles. broken covers. etc.? If so, exolain in comments below. <br />Tank #1 ❑ Yes ❑ No <br />Tank #2 ❑ Yes ❑ No <br />Pump Tank ❑ Yes ❑ No <br />System <br />❑ Structural integrity <br />❑ Structural integrity <br />❑ Structural integrity <br />❑ Mound <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: A wastewater Treatment Plant �—lYT-jr +G'y� <br />Disposal Site: <br />Lime: <br />Gallons <br />Plowed: ❑ Yes ❑ No <br />Time: <br />Temperature: <br />pH: > 12 ❑ <br />Time: <br />Temperature: <br />pH: > 12 0 <br />®R WON <br />= 4 ar VA <br />