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Date: <br />Owner: <br />Property address: <br />Information <br />21- <br />a-� phone#: <br />d <br />Owners address: (if different) <br />-- <br />—' Tanis InfCorrmuatam�n <br />Reason for p umjphRgg <br />C] compliance inspection ❑ <br />holding tank EF°�' a'ir tenance <br />I`Uthool of acdesso <br />C] manholes ❑ <br />inspection pipe (holding tanks only) <br />(owner signature req'd if refusing to allow pumping through maintenance hole) <br />CCon rdi lion of taus =. <br />Ater cleaned: files <br />baffles good: Yes <br />alarm working: files <br />No <br />No <br />No <br />n/a <br />n/a <br />n1a <br />Tnnh l nWage nP®scr<ved-. <br />above operating depth: <br />Yes No (repairs recommended) <br />below operating depth: <br />_Yes No (failing to protect groundwater) <br />Gallons removed-, <br />#ll �'f " #2 /� L, �;' � <br />43 _ 44 pump tank A&4:5z-�' _ total <br />may` <br />Bisp®sal Me lnodl- <br />municipal [11--� <br />Location: <br />land apply ❑ <br />Location: <br />�a�cety c®rnc�u�r�so <br />Recommended rrcelAanlQw- <br />CComrrmcents: � <br />I hereby certify that I have completed this work in accordance with AIN 70133.0770 and any local requirements. <br />r3yaity tion or guarantee offuture system performance has been nor can be made. <br />Chip's Septic Service LLC SSTS :License <br />Maintairibr signature 16762 Babcock Mehue #2064 <br />Lester Prairie, M.N. 55354 <br />(952) 200-3176 <br />