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DUANE� <br />Septic Service, LLC <br />1205 LaBeaux Ave NE <br />St. Michael, MN 55376 <br />n ATC ( — I (_ - Z ?- <br />Maintenance Inspection Form <br />MPCA Lic. # 654 <br />Maintainer D Jim <br />Duane <br />ick <br />• Phone: 763-497-2764 <br />• Email: duaneseptic@centurylink.net <br />1. INVOICE <br />, , <br />Pumping Fee:3 ��, <br />Scum/Sludge Measured <br />Maintenance Holes Securely Replaced: <br />Name: <br />r <br />6'r-. <br />❑ Yes C7 No <br />Long Pull Fee: <br />Mound <br />0 Risers leaking <br />Addres <br />❑ Risers leaking <br />❑ Elevated dralnfield <br />❑ Baffles <br />❑ Baffles <br />❑ Baffles <br />Zp <br />}C4rNnPu <br />❑ Non-domestic waste <br />Other Repairs: <br />❑ Trenches <br />City/State/Zip: <br />❑ Non-domestic waste <br />❑ Ponding/Surfacing <br />w- 4 <br />❑ Effluent Filter/screen <br />❑ Other: <br />¢- <br />Cleaned? ❑ Yes ❑ No <br />Total Cost of Service:�thc.ti(C <br />Comments: <br />Payment Method: <br />--?53% <br />[TCheck ❑ Cash <br />ElCredit <br />y yo , <br />y �o <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 />structurals <br />unsound <br />eptic/holding Tank #1 <br />13 Yes <br />LYf�_ <br />❑Yes <br />R-151-0—❑Yes <br />E"I�O' <br />Gallon : C�.9Q <br />❑ Septic/holding Tank #2 <br />❑ Yes <br />C No <br />❑ Yes <br />RIG <br />❑ Yes <br />®'Iqo <br />Gallons: <br />❑ Pretreatment Tank <br />❑ Yes <br />❑ No <br />❑ Yes <br />❑ No <br />❑ Yes <br />❑ No <br />Gallons: <br />Pump Tank <br />El Yes <br />�� <br />3 -N -o <br />❑ Yes <br />U-90--"' <br />YNo <br />EI. Yes <br />®`tom <br />Gallons: CR2� <br />How Accessed: aintenance Hole <br />Scum/Sludge Measured <br />Maintenance Holes Securely Replaced: <br />Reason For Pumping: <br />❑ Other (see attached) <br />❑ Yes C7 No <br />C3"1'es ❑ No <br />Mound <br />Did you Identify any operational issues or unsafe conditions while assessing the sewage tanks In this system, I.e., <br />rrarkarl rankc_ micsinn hefFles. hrnken covers. etc.? If so. exolaln In comments bsJow. <br />Tank #1 ❑ Yes o <br />Tank #2 ❑ Yes o <br />Pump Tank ❑ Yes No <br />System <br />❑ Structural integrity <br />❑ Structural integrity <br />❑ Structural Integrity <br />Mound <br />0 Risers leaking <br />❑ Risers leaking <br />❑ Risers leaking <br />❑ Elevated dralnfield <br />❑ Baffles <br />❑ Baffles <br />❑ Baffles <br />'❑ Pressure bed <br />❑ Non-domestic waste <br />❑ Non-domestic waste <br />❑ Electrical Issues <br />❑ Trenches <br />❑ Non-domestic waste <br />❑ Ponding/Surfacing <br />❑ Effluent Filter/screen <br />❑ Other: <br />Cleaned? ❑ Yes ❑ No <br />Comments: <br />Disposal: B -i and Application: ❑ Wastewater Treatment Plant <br />Disposal Site: <br />Lime: Gallons Z ioO <br />Plowed: <br />❑ Yes <br />--M-No <br />Time: <br />9e ,0 Temperature: <br />(v � <br />pH: <br />Z , x <br />> 12 <br />Time: <br />cjg(p Temperature: <br />(r (,a <br />pH: <br />> 12 IT- <br />N� _ VAL V�.' � <br />