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Septic Tank Pumping / Maintenance <br />Owner Information <br />Date: Z 3 <br />Owner:_ ",'_ /�/ e; Phone#: Z <br />Property address: �--�- Owners address: (if different) <br />`a<0 <br />®� 0,7 v r1'1 35 <br />Tank Information <br />Reason for Pumping: ❑ compliance inspection ❑ holding tank 9 -maintenance <br />Method of access: manholes ❑ inspection pipe ( holding tanks only) <br />(owner signature req'd if refusing to allow pumping through maintenance hole) <br />Condition of tanks: <br />filter cleaned: <� baffles good: alarm working: (0) <br />No No No <br />n/a n/a n/a <br />Tank leakage observed: above operating depth: Yes o (repairs recommended) <br />below operating depth: Yes (failing to protect groundwater) <br />Gallons removed: <br />#1 160o #2 --� #3 _ #4 pump tank d total ZSa U <br />Disposal method: municipal location: az� e4 % <br />I Safety concerns: <br />/1 m <- <br />Recommended repairs: <br />4 dY`'L <br />I Comments: <br />6e,C <br />land apply ❑ location: <br />4 <br />- .s., k4 <br />>� � A? I-"- <br />1 hereby certify that I have completed this work in accordance with MN 7083.0770 and any local requirements. <br />No det on or guarantee offuture system performance has been nor can be made. <br />Chip's Septic Service, LLC _ SSTS License <br />Maintainer si nature 16762 Babcock Avenue #2064 <br />Lester Prairie, MN. 55354 <br />(952) 200-3176 <br />