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Septic Tank Pumping/Maintenance <br />Owner Information <br />Date: _& - /7 -9- Phone: <br />Owner: )?6mlEmail: <br />Property Address: Owner's Address <br />15- <br />Deono AW ss3S(� <br />Tank Information <br />.�- • G9 l } -7970 <br />(if different) <br />Reason for Pumping: <br />❑ Complinace Inspection <br />❑ Holding Tank <br />(Maintenance <br />Method of Access: <br />Manholes <br />❑ Inspection Pipe <br />(holding tanks only) <br />(Owner's signature req'd if refusing to allow pumping through maintenance hole) <br />Condition of Tanks: <br />Filter Cleaned <br />Xs, Baffles good: <br />Y <br />Alarm working: e0l <br />No <br />No <br />N/A <br />N/A <br />N/A <br />Tank Leakage Observed: Above operating depth <br />Below operting depth <br />Gallons Removed: <br />#1 /,�Uc► #2 1,5Uv #3 #4 <br />Disposal Method: Municipal: Q <br />Land Applied: ❑ <br />Safety Concerns: <br />mended Repairs: <br />omments: <br />Yes/,/ (repairs recommended) <br />Yes/10 (failing to protect groundwater) <br />tank <br />Total <br />Location: Watertown Wastewater Facili <br />Location: <br />1 hereby certify that I have completed this work in accordance with MN 7083.0770 and any local requirements. <br />No determination or guarantee offuture system erfomance 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, NIN. 55354 <br />(952) 200-3176 <br />chipseptic(bgmail.com <br />revised 312025 <br />