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Septic Service, LLC <br />1205 LaBeaux Ave NE <br />St, Michael, MN 55376 <br />`?. '-n . -? 2 <br />Maintenance Inspection Form <br />MPCA Lic. # 654 <br />Maintainer Jim <br />[� Duane <br />Nick <br />• Phone: 763-497-2764 <br />• Email: duaneseptic@centurylink.net <br />INVOICE <br />Pumping Fee: �7D <br />Name: (C <br />Pump Tank ❑ Yes Fffo <br />Long Pull Fee: <br />❑ Structural integrity <br />Address: <br />❑ Structural integrity <br />❑ Risers leaking <br />Mound <br />11 Elevated drainfield <br />Other Repairs: <br />❑Risers leaking <br />City/State/Zip; <br />El Pressure bed <br />❑ Baffles <br />❑ Non-domestic waste <br />❑ Baffles <br />❑ Non-domestic waste <br />❑ Electrical Issues <br />❑ Trenches <br />❑ Non-domestic waste <br />Total Cost of Service: <br />Payment Method: ❑ Check <br />❑ Cash <br />❑ Credit <br />Cleaned? ❑ Yes ❑ No <br />Comments: <br />Maintenance hole cover is damaged, <br />Tank (check if present) <br />Tank leaks below the <br />designed operating depth <br />Tank leaks above the <br />designed operating depth <br />cracked, unsecured, or appears to be <br />structural) unsound <br />eptic/h l ing Tank #1 <br />❑ Yes <br />❑ Yes es <br />❑ Yes <br />U -111o' <br />Gallons: <br />eptic/hold' g Ink #2 <br />El Yes l�� <br />ElYe s U -M <br />El <br />© 10 <br />Gallons: a <br />❑ Pretreatment Tank <br />❑ Yes Cl No <br />❑ Yes ❑ No <br />❑ Yes <br />❑ No <br />Gallons: <br />�Jo <br />Pump Tank <br />Gallons:Id- <br />❑ Yes o <br />❑ Yes <br />❑ Yes <br />How Accessed: aintenance Hole Scum/Sludge Meassureedd - Maintena_nce�Holes Securely Replaced: Reason Fo umpmg: <br />T <br />❑Other see attached) El Yes C�"No Cd'i'es ❑ No <br />c <br />Did you Iden'16y ry operational Issues or unsafe conditions while assessing the sewage tanks In this system, I, e., <br />1n r —Pntc halnw. <br />Tank #1 EI Yes o <br />Tank #2 ❑Yes o <br />Pump Tank ❑ Yes Fffo <br />System <br />❑ Structural integrity <br />❑ Structural integrity <br />❑ Structural integrity <br />❑ Risers leaking <br />Mound <br />11 Elevated drainfield <br />O Risers leaking <br />❑Risers leaking <br />❑Baffles <br />El Pressure bed <br />❑ Baffles <br />❑ Non-domestic waste <br />❑ Baffles <br />❑ Non-domestic waste <br />❑ Electrical Issues <br />❑ Trenches <br />❑ Non-domestic waste <br />❑ Ponding/Surfacing <br />❑ Effluent Fllter/screen <br />❑ Other: <br />Cleaned? ❑ Yes ❑ No <br />Comments: <br />Disposal: O Land Application: u wastewater ireatmuin main <br />Disposal Site: +-f Lime: Gallons Z duc> Plowed: ❑ Yes ,Q -No <br />Time: `l °U Temperature: —iv pH: t L, > 121-ff <br />Time: 5< o cr Temperature: -1 t pH: t-2 3 > 1 21-E] <br />