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Septic Tank Pumping/Maintenance <br />Owner Information <br />Date: _, - f - Phone: <br />Owner: —MC!QL4 Email: <br />Property Address: L Owner's Address (if different) <br />�]p <br />Reason for Pumping: <br />Method of Access: <br />(Condition of Tanks: <br />Filter Cleaned <br />Leakage Observed: <br />Gallons Removed: <br />#1 1yN-V,% #2 <br />(Disposal Method: <br />(Safety Concerns: <br />Recommended Repairs: <br />Comments: <br />Tank Information <br />❑ Complinace Inspection ❑ Holding Tank V Maintenance <br />7— Manholes ❑ Inspection Pipe (holding tanks only) <br />J (Owner's signature req'd if refusing to allow pumping through maintenance hole) <br />Yes Baffles good: ec <br />s Alarm working: <br />No No <br />YA N/A N/A <br />Above operating depth Yes/ <br />,Vo (repairs recommended) <br />Below operting depth Yes/I�o (failing to protect groundwater) <br />#3 <br />Municipal: <br />Land Applied: <br />#4 <br />tank <br />Total �0 <br />Q Location: Watertown Wastewater <br />❑ Location: <br />I hereby certify that I have completed this work in accordance with AN 7083.0770 and any local requirements. <br />No determination or guarantee offuture s mane has been nor can be made. <br />Chip's Septic Service, LLC & SSTS <br />Swartzer's Sewer Services �-� License <br />16762 Babcock Avenue Maintaner Signature #2064 <br />Lester Prairie, MN. 55354 <br />(952) 200-3176 <br />chipseptic9amail.com <br />revised 312025 <br />