HomeMy WebLinkAbout6351 Argenta Trl W - Septic Maintenance Form 9-25-25`u
Sewae tank maintenance • reporting
•
Reporting information
Date of maintenance (mm/dd/yyyy):
Property address: r IR t
City:
Property owner's name: G
Property -owner's address if different:
Reason for maintenance:
Parcel ID:
L f State: 4/1 ;v Zip code: 5 j c:.
City: State: Zip code:
1.
2.
0
4
5.
6.
7.
8.
9.
Access used to remove septage: ❑ Maintenance hole Erother (Unless a holding tank, go to #3 below)
If the maintenance hole was used, were all covers secured in place? ❑ Yes ❑ No If no; please explain below:
If the owner refuses to allow a Subsurface Sewage Treatment System (SSTS) to be pumped through the maintenance
hole, have them complete and sign the following statement.
refuse to allow the removal of the solids and liquids through the maintenance
(Pnnt owners name)
hole. I understand that removal of solids and liquids through other access points is not considered a compliant method of
solids removal and does not fulfill the solids removal requirements of Minn. R. 7080.2450 and 7082.0600.
By typing/signing my name below, I certify the above statements to be true and correct, to the best of my knowledge, and
that this information can be used for the purpose of processing this form.
Owner's signature: Date (mm/dd/yyyy):
Is the tank designed as a leaky tank? (Example: seepage pit, cesspool, drywell, leaching pit)
Tank #1: ETYes ❑ No Verification method used: _
Tank #2: ETYes ❑ No Verification method used:
Tank check if resent
Tank leaks below the
designed operating depth
Tank leaks above the
designed operating depth
Maintenance hole cover is
damaged, cracked, unsecured, or
appears to be structural) unsound
❑ Septic/holding Tank #1
El Yes
❑ No
ETYes
❑ No
❑ Yes ❑ No
❑ Septic/holdingSeptic/holding Tank #2
Q Yes
❑ No
[Yes
❑ No
❑ Yes ❑ No
❑ Pretreatment Tank
❑ Yes
❑ No
[a"Yes
❑ No
❑ Yes ❑ No
❑ Pump Tank
❑ Yes
❑ No
❑ Yes
❑ No
❑ Yes ❑ No
Describe detail for any "Yes"
How many gallons of septage were removed?
Tank #1: Tank #2: Pretreatment Tank:- Pump Tank:
Where was the septage taken? E3Wastewater treatment facility ❑ Land application ❑ Other
Explanation (Facility name/Site #): —
Did you identify any operational issues or unsafe conditions while assessing the sewage tanks in this system?
❑ Yes ❑ No If yes, identify tank and explain:
❑ Evidence of non -domestic waste ❑ Baffle(s) condition ❑ Effluent screen
❑ Maintenance hole and extensions condition ❑ Other conditions (e.g. structural integrity of tank or lid, electrical hazard, etc.)
Gvnlanatinn
List any troubleshooting and minor repairs completed or declined by owner:
❑ Troubleshooting and repairs conducted: I ❑ Repairs declined by owner:
Additional comments or suggestions for owner's consideration:
Pumping record
Company information
Pinky's Sewer Service
PO Box 354 Afton, MN 55001
651-439-4847
MN License 4251
WI License 2118 Employee's signature: