Reporting Information

Date of maintenance:	Reason for maintenance:
Property address:	City:	State:	Zip:
Property owner’s name:
Site Name:
1.	Access used to remove septage:	Maintenance hole
2.	If maintenance hole was used, were all covers securely replaced?	Yes No please explain
Explanation:
3.	Is there evidence of tank leakage from a septic, holding, pretreatment or pump tank below the operating depth or evidence of damaged, cracked or structurally unsound maintenance hole covers?
Tank	Leaking out	Leaking in	Cover damage
Septic/holding Tank #1	Yes No	Yes No	Yes No
Septic/holding Tank #2	Yes No	Yes No	Yes No
Pretreatment Tank	Yes No	Yes No	Yes No
Pump Tank	Yes No	Yes No	Yes No
4.	Characteristics of Tanks (Gallons of septage removed, sludge thickness, scum thickness, baffle depth, baffle length)
Tank #1:	Tank #2:	Pretreatment Tank:	Pump Tank
Gallons removed
Scum thickness
Sludge thickness
Baffle Depth
Baffle Length
Tank Depth
5.	Is there any sensory (smell and/or sight) evidence of non-domestic wastes?
Yes No	Please explain:
Disposal site:	Wastewater treatment plant	Land application	Other (please explain below)
Explanation:
List any troubleshooting, minor repairs conducted, tank safety* concerns or other concerns:
6.	Certification:	I hereby certify as a State of Minnesota-certified SSTS Maintainer that I personally conducted the work and made the observations, or directly supervised others in the performance of this job.
Maintainer’s name and address:
Maintainer’s license #:	Maintainer’s phone:
Maintainer’s signature:	Date: