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Septic Service, LLC <br />1205 LaBeaux Ave NE <br />St. Michael, MN 55376 <br />DATE Z S Z '-/ <br />Maintenance Inspection Form <br />MPCA Lic. #L4286 <br />Maintainer Q Jim <br />lick <br />• Phone: 763-497-2764 <br />• Email: duaneseptic@centurylink.net <br />INVC)lrF <br />Pumping Fee:Name: <br />�2 <br />Tank #2 ❑ Yes No <br />Pump Tank ❑ Yes No <br />S4(2Ue <br />C' - <br />Scum/Sludge Measured <br />Long Pull Fee: <br />c <br />ElOther (see attached) <br />Address: <br />= <br />Vl.� L_ <br />Other Repairs: <br />EY -Baffles <br />❑ Baffles <br />City/State/Zip: <br />❑ Non-domestic waste <br />❑ Non-domestic waste <br />❑ Electrical issues <br />❑ Trenches <br />❑ Non-domestic waste <br />❑ Ponding/Surfacing <br />Total Cost of Se e: <br />❑ Effluent Filter/screen <br />❑ Other: <br />Payment Method: ❑ Check ❑ Cash <br />❑ Credit <br />r <br />Comments: <br />Tank (check if present) <br />Tank leaks below the <br />Tank leaks above the <br />Maintenance hole cover is damaged, <br />cracked, unsecured, or appears to be <br />designed operating depth <br />designed operating depth <br />structural) unsound <br />Septic/holding Tank #1 <br />Gallons: � 2 <br />❑ Yes <br />rJ No <br />El Yes �o <br />El Yes <br />®-90 <br />Septic/holding Tank #2� <br />#2E) <br />Yes <br />No <br />❑Yes ❑'No <br />11 Yes <br />o <br />Gallons: 2 So <br />❑ Pretreatment Tank <br />Gallons: <br />❑ Yes <br />❑ No <br />El Yes El No <br />El Yes <br />❑ No <br />Pump Tank <br />/� <br />❑ <br />❑ <br />2 -No <br />Gallons: 12-510 <br />❑ Yes <br />Z_ No <br />Yes <br />Yes <br />Did you identify any operational issues or unsafe conditions while assessing the sewage tanks in this system, i.e., <br />cracked tanks, missino bafFles, broken covers, etc.? Ifso, explain in comments -below. <br />Tank #1 ❑ Yes o <br />Tank #2 ❑ Yes No <br />Pump Tank ❑ Yes No <br />System <br />How Accessed: Maintenance Hole <br />Scum/Sludge Measured <br />Maintenance Holes Securely Replaced: <br />Reason For Pumping: <br />ElOther (see attached) <br />0 es El No <br />❑Yes ElNo <br />Vl.� L_ <br />Did you identify any operational issues or unsafe conditions while assessing the sewage tanks in this system, i.e., <br />cracked tanks, missino bafFles, broken covers, etc.? Ifso, explain in comments -below. <br />Tank #1 ❑ Yes o <br />Tank #2 ❑ Yes No <br />Pump Tank ❑ Yes No <br />System <br />El Structural integrity <br />El Structural integrity <br />El Structural integrity <br />ound <br />❑ Risers leaking <br />❑ Risers leaking <br />❑ Risers leaking <br />❑ Elevated drainfield <br />❑ Baffles <br />EY -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: r1 _Wastewater Treatment Plant <br />Disposal Site: <br />Lime: <br />Gallons ,-: jba <br />Plowed: ❑ Yes <br />❑ No <br />Time: <br />Temperature: <br />pH: <br />> 12 ❑ <br />Time: <br />Temperature: <br />pH: <br />> 12 ❑ <br />