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Jim Eicher Maintenance Inspection Form <br /> 4• MPCA Lic. # 654 <br /> Maintainer 1 1 Jim <br /> ,,,,,irt, <br /> , I 1 Duane <br /> DVA - lS f 1 Nick <br /> Septic Service, LLC <br /> 1205 LaBeaux Ave NE • Phone: 763-497-2764 <br /> St. Michael, MN 55376 • Email: duaneseptic@centurylink.net <br /> DATE INVOICE <br /> Pumping Fee: Name: <br /> Long Pull Fee: Address: <br /> Other Repairs: City/State/Zip: <br /> Total Cost of Service: Payment Method: ❑ Check ❑ Cash ❑ Credit <br /> Tank leaks below the Tank leaks above the Maintenance hole cover is damaged, <br /> Tank(check if present) designed operating depth designed operating depth cracked,unsecured,or appears to be <br /> structurally unsound <br /> ❑ Septic/holding Tank#1 ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Gallons: <br /> ❑ Septic/holding Tank#2 <br /> Gallons: ElYes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> ❑ Pretreatment Tank ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Gallons: <br /> ❑ Pump Tank ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Gallons: <br /> How Accessed:❑Maintenance Hole Scum/Sludge Measured Maintenance Holes Securely Replaced: Reason For Pumping: <br /> ❑Other(see attached) ❑ Yes ❑ No ❑ Yes ❑ No <br /> Did you identify any operational issues or unsafe conditions while assessing the sewage tanks in this system, i.e., <br /> cracked tanks, missing baffles, broken covers, etc.?If so, explain in comments below. <br /> Tank#1 ❑ Yes ❑ No Tank#2 ❑ Yes ❑ No Pump Tank ❑ Yes ❑ No System <br /> ❑ Structural integrity ❑ Structural integrity ❑ Structural integrity E Mound <br /> ❑ Risers leaking ❑ Risers leaking ❑ Risers leaking ❑ Elevated drainfield <br /> ❑ Baffles ❑ Baffles ❑ Baffles ❑ Pressure bed <br /> ❑ Non-domestic waste ❑ Non-domestic waste ❑ Electrical issues ❑ Trenches <br /> ❑ Non-domestic waste ❑ Ponding/Surfacing <br /> - ❑ Effluent Filter/screen ❑ Other: <br /> Cleaned? ❑Yes ❑ No <br /> Comments: <br /> Disposal: ❑ Land Application: ❑Wastewater Treatment Plant <br /> Disposal Site: Lime: Gallons Plowed: ❑ Yes ❑ No <br /> Time: Temperature: pH: >12 ❑ <br /> Time: Temperature: pH: >12 ❑ <br /> ,k .A �41W46.,r.* C�glLt THANKS! 0 to) ,,e,%:,,0......10 <br /> " .— <br /> i'°..4",-..1---...6-.W...-411 11i i '4Pr:...- 1 <br />