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Septic Tank Pumping / Maintenance <br />Owner Information <br />Date: <br />Owner: ���✓o rte, ��y Phone#: <br />Property address: Owners address: (if different) <br />Reason for Pumping: <br />Method of access: <br />Condition of tanks: <br />filter cleaned: <br />Cc4) No <br />J n/a <br />Tank leakage observed: <br />Gallons removed: <br />#1 000 #2 /000 <br />Disposal method: <br />Safety concerns: <br />Recomme ded repairs- <br />Tank In <br />❑ compliance inspection ❑ holding tank Maintenance <br />manholes ❑ inspection pipe (holding tanks only) <br />(owner signature req'd if refusing to allow pumping through maintenance hole) <br />good: � alarm working: � <br />see - <br />baffles ) <br />No <br />n/a <br />above operating depth: Yes o <br />below operating depth: Yes <br />No 01— <br />n/a <br />(repairs recommended) <br />(failing to protect groundwater) <br />#3 #4 pump tank total 0 <br />municipal [ location: <br />land apply ❑ <br />ZX I <br />location: <br />I hereby certify that I have completed this work in accordance with MN 7083.0770 and any local requirements. <br />No ation or guarantee of fixture system performance has been nor can be made. <br />Chip's Septic Service, LLC SSTS License <br />Maintainer signature 16762 Babcock Avenue #2064 <br />Lester Prairie, MN. 55354 <br />(952)200-3176 <br />