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Property address: 4685 West Branch Rd Parcel ID: 07-117-23-22-0015 <br />City: Orono State: MN Zip code: 55364 <br />S. Is the tank designed as a leaky tank? (Example: seepage pit spoof, dryweq, leaching pit) <br />Tank #1: ❑ Yes (q No Verification method used: -- <br />Tank #2: ❑ Yes ❑ No Verification method used: <br />6. Is there evidence of the following? <br />Tank check if resent <br />Tank teaks below the <br />designed rating de th <br />Tank leaks above the <br />designed operating depth <br />Maintenance hole cover is <br />damaged, sacked, unsecured, or <br />ammrs to be dructuraft unsound <br />Se ticlholdin Tank #1 <br />Yes <br />No <br />Yes <br />No <br />11Yes No <br />Septic/holdingSeptic/holding Tank #2 <br />El YesFNo <br />No <br />Yes <br />Yes <br />Yes <br />o <br />No <br />HNo <br />Yes Q No <br />Yes No <br />Yes No <br />Pretreatment Tank <br />Yes <br />Pump Tank <br />r3 Yes Or No <br />Describe detail for any "Yes' <br />7. How many gallons of septage were removed? <br />Tank #1: 49,00` Tank #2: l ij J Pretreatment Tank: Pump Tank: S%6u <br />8. Where was the septage taken?p Waste_watef treatment facility ❑ Land application ❑ Other <br />Explanation (Facility name/Site #): <br />9. Did you identify any operational issues or unsafe conditions while assessing the sewage tanks in this system? <br />❑ Yes 4'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, electrkal hazard, etc.) <br />Explanation: <br />10. List any troubleshooting and minor repairs completed or declined by owner. <br />Additional comments or suggestions for owner's consideration: <br />Pumping record <br />l 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 noncertiiied 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 />By typing/signing my name below, I certify the above statements to be true and correct, to the best of my knowledge, and that <br />this information can be used for the purpose of processing this form. <br />Company Information Employee information <br />Company name: Kothrade Sewer, Water 8 Excavating Inc Print name: L. Bursch <br />Business license number: MPCA 192 Certification number. tirsp ruble?: C9199 <br />Email: info kothrade.com Phone number: 763-49t3-8702 <br />Employee's signature: Date (mm/dd/yyyy): � 7 <br />www.pea.state.mn.us • 651-296-6300 • 800-657-3964 Use your preferred relay service • Available in alternative formats <br />w4-wwfsts4-36 • 41201 <br />Page 2 of <br />