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Property address: 3076 Farview Ln <br />City: Orono State: MN <br />Parcel ID: 04-117-23-33-0006 <br />Zip code: 55356 <br />S. Is the tank designed as a leaky tank? (Example: seepage pit, ces pool, drywell, leaching pit) <br />Tank #1: ❑ Yes �B 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 leaks below the <br />desi ned operating depth <br />Tank leaks above the <br />designed operating depth <br />Maintenance hole cover is <br />damaged, cracked, unsecured, or <br />appears to be structural1 unsound <br />Septic/holdingSepticlholdlng Tank #1 <br />0 Yes <br />Oft <br />Q Yes <br />No <br />❑ Yes o <br />❑ Septic/holdingSeptic/holding Tank #2 <br />❑ Ye <br />0 Yes <br />No <br />❑ Yes P No <br />El Pretreatment Tank <br />❑ Ye <br />El Yes <br />No <br />❑ Yes 0 No <br />❑ Pump Tank <br />❑ Yes <br />No <br />❑ Yes <br />No <br />El Yes o <br />Describe detail for any "Yes" <br />7. How many gallons of septage were removed? <br />Tank #1: 7WO� Tank #2:_ i W d Pretreatment Tank: <br />8. Where was the septage taken? <br />Explanation (Facility name/Site # <br />Pump Tank: I* C) <br />facility ❑ Land application ❑ Other <br />9. Did you -identify any operational issues or unsafe conditions while assessing the sewage tanks in this system? <br />❑ Ye o 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, electrical hazard, etc.) <br />Explanation: <br />10. List anv troubleshooting and minor repairs completed or declined by owner: <br />Additional comments or suggestions for owner's consideration: <br />Pumping record <br />! 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 noncertified 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 & Excavating, Inc Print name: L. Bursch <br />Business license number: MPCA 192 Certification number: of applicable): C9199 <br />Email: info kothrade.com Phone number: 763-498-8702 <br />Employee's signature: Date (mm/dd/yyyy): y <br />www.pca.state.mn.us • 651-296.6300 • 800.657-3864 • Use your preferred relay service • Available in alternative formats <br />wq-ww1sts4-38 • 4128121 Page 2 of 3 <br />