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Oct, 22. 2012 11 : 15AM No, 1004 P, 7
<br /> Reporting Information
<br /> Date of m�lntenance: �a vZ7-J� Rea�on for maintenance: � C �,n
<br /> Property address: 3p(�D �.�j��,,� �.�v Cfty: p Rbv�d State; W1N Zip:
<br /> PropeRy owner s nama, A�I� �a�S�ei� ��
<br /> Property-owne�'s address if dii�eren�
<br /> ���Y= _. State: Zip� Phone: Fax;
<br /> 1. AaceBS used to rentOve sepfage; �Malntenance hofe ❑Olhel'(Go to�t3 below)
<br /> 2. If maintenanoe hole wes used,were all covel's 9ecurely replaced9 I�,Yes Q No pleese explain
<br /> Explenatfon�
<br /> 3. If owner re(use�to ollow a Subau�ace 3ewage Treafinent Syatem (SSTS)to bo pumped throug�the malntenanoe hole,
<br /> have them oomplete and 91gn the follvwing staternent
<br /> ��_ ,refuse to allvw the removal of 1he solids end Ilquids through lhe malntenance
<br /> (Owner's namA)
<br /> hole. I understand that removel o(sollde end liquids through olher access polnls is not cnnside�ed mainlensnce,
<br /> Owner's signeture: Date;
<br /> 4. Is the tank deslgned as a le�ky tank?(Example:seepege pit, oesspool, drywell,leaching pit)
<br /> Tank#1: ❑Yes �No VerlFlcatlon method uaed? 1 �a,�y1L�
<br /> Tehk#2: Q Yes [�No Verification mefhod used?�'�w�Q�,��,�,�,�5
<br /> 6. le there evldence of tahk leakage from a septic, holdfng,pretreatment or pump tank bolow the operat1ng depth or
<br /> evidence of demaged,cracked or struclu��lly unsound maintanance hole cavore9
<br /> Tank Leakin out _ Leakin in Cover dama e
<br /> Se tic/holdin Tank#1 Yes No Yes �,No ❑ Yes No
<br /> Se tldholdin Tank#2 ❑Yes No ❑Yes No ❑Yes No
<br /> Pretreatrnent Tank Yes ❑ No ❑Yes ❑ No ❑Yes ❑No
<br /> Pum Tank ❑Yes No ❑Yes No ❑Yes No
<br /> 6. How meny ga�lo�e of�eptege were removed9
<br /> Tank#1; _l ppp , Tank#2:�QQ Pretreetment Tenk; Pump Tank: ��C�
<br /> 7. la there any sen6ory(smell and/o�sight)evidence of non-dorneauC wa6te�s7
<br /> ❑Yes �No Please eXplain_
<br /> Dlsposal sfte: ❑Wesleweter treatment pl�nt I,�Land applicatlon ❑Other(p/ease exple►n beloW)
<br /> Explanatlon:
<br /> Llst eny troubleshooting,minor repelrs conducted,tank sataty•cortcerns or other eoncems�
<br /> 8. Cer'llfication; I hareby certiiy as a Sts1e of Minnesota-certifed SSTS Melntainer that I pe�sonelly conduc[ed the work end
<br /> made the observetlons,or dlrectly supervised others in the periormance af this job.
<br /> Maintainer's name and address; Kolhrade Sewer,Water 8�Excaveting, Inc., 12059 Whitefail La, Hanover,MN 56341
<br /> Malntalner's license#: 0192 Maint�iner's phone; 763,489,8702
<br /> Malntainers signature: —�.. oate: � A27//
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