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icher <br /> Maintenance Inspection Form <br /> MPC A Lic. #L4286 <br />> Maintainer Jim <br /> ❑ Nick <br /> Service, LLC • Phone: 763-497-2764 <br /> aBeaux Ave NE <br /> lad, MN 55376 • Email: duaneseptic@centurylink.net <br /> 5- 7/Z i1/ INVOICE <br /> g Fee: /J 0 <br /> Name: / <br /> —E�,202 J jb(;a (,- l�viJ Er.,, �` 55'rL t Sie ph' cn Le...., <br /> ill Fee: Address: D <br /> epairs: City/State/Zip: <br /> 0ror' t) <br />)st of Service: _ _ Payment Method: ❑ Check ❑ Cash ❑ Credit <br /> Tank leaks below the Tank leaks above the Maintenance hole cover is damaged, <br /> ink(check if present) cracked, unsecured,or appears to be <br /> designed operating depth designed operating depth <br /> structurally unsound <br />;MoldingTank#1 <br /> ❑ Yes 0 No ❑ Yes No ❑ Yes No <br />/holding Tank#2 ❑ Yes o ❑ Yes ❑ Yes C<No <br /> atment Tank ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Tank ❑ Yes E.:1,110 ❑ Yes Cr No ❑ Yes No <br />;essed: aintenance Hole Scum/Sludge Measured Maintena�nc Holes Securely Replaced: Reason For Pumping: <br /> ❑Other(see attached) ❑Yes s"No -t"1 Yes ❑ No i <br /> Did you identify any operational issues or unsafe conditions while assessing the sewage tanks in this system, i.e., <br /> creed tanks,missing baffles, broken cov etc.?If so, explain in comments low. <br /> ❑ Yes f iol o Tank#2 ❑ Yes 0'No Pump Tank ❑ Yes iii,eFlo System <br /> Structural integrity ❑ Structural integrity ❑ Structural integrity 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 /> nts: <br /> Disposal: ❑ Land Application: ,17Wastewater Treatment Plant IA,e_N i`.e,-i t; � <br /> LI Site: Lime: Gallons Plowed: ❑ Yes ❑ No <br /> Temperature: pH: >12 ❑ <br /> Temperature: pH: >12 ❑ <br /> �� ,,.,.� QC. THANKS! ,., • <br /> 0�� <br />