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Property address: 40 Trufula Trail (Luis & Veronica Acosta parcel 1o: 33_118-23-44-0035 <br />city: Orono ._ .. — state: MN _ zip code:_5535§ <br />Optional section: Sewage Tank Compliance Certification <br />This form does not represent a complete system inspection report and only cartiflies smgge tank compliance status. <br />lnstrr dons: This section of the form may be completed and signed bsks sass the complianceiied Individual <br />(D tof a each slicensed <br />a tank <br />Maintenance Business who personally conducts the necessary procedures <br />in <br />the system. <br />When this section of the form is signed by a qualified certified professional, it becomes neeessery sum documentatbn to an <br />Existing System Compliance inspection Report: Tian n Than - FAsjnQ MM= This form can be <br />found on the MPGA website at n jh w v . te-mn-ma&aLe rxi pis technical-and-0ornali�nte The information and certified statement on this form is required when existing septic tank compliance status is determined by an <br />1ndlvidual other than the SSTS Inspector that submits the inspection report. It represents a third party assessment of SSTS <br />component compliance mil is allowable under Minn. R. 7082.07D0, subp. 4 item (B) subitem (1). This form is valid for a period of <br />three yean3 beyond the signature date on this form unless a new evaluation is requested by the owner or owner's agent or Is <br />required according to local regulations. Additional Administrative Rule references for this activity can be found at Minn. <br />R. 7082.0700, subp. 4 sterns B, C, and D: 7083.0730 item C. <br />]gCwtificsts of sewage tank compliance <br />Aifrm all three statements: <br />]� The sSTS does not contain a seepage pit, cesspool. <br />dryweil, leaching pit, or other pit. <br />Jg It does not contain a sewage tante that was designed <br />to be watertight, but subsequently leases below the <br />designed operating depth, <br />It does rust represent an imminent safety threat by <br />reason of unsecured, damaged, or weak <br />maintenance hole cover(s) or other unsafe condition. <br />Company Informiation <br />Company name: Albin°s Septic Pumping, -LLC <br />Business Ik erm number: 3346 _T__ <br />❑ Notice of sewage tank non-compliance <br />Select ail that apply: <br />E] The 'SSTs hes a seepage psi, cesspool, drywall, <br />teaching pit, or other pit. <br />❑ It has a sewage tank that was designed to be <br />watertight, but subsequently 'leaks below the designed <br />operating depth. <br />❑ It presents a threat topublic safety by reason of <br />unsecured, damaged, or weak maintenance hflie <br />cover(s) or other unsafe condition - <br />Designated Certified Individual (DCI] Inforrnatlon <br />Print name: Peter Peterson_ <br />Certification number: 9227 <br />I persmnak"y conducted the mrk descni#ed above as a oesignated Ceitftd Iron oduaf of a Mhvsdta-Iikensed SSTS Maim`Wawe <br />Business. l,persornatly aondacted the ry procedures to assess the compliance status of each sewage tank in this SSTS. <br />Designated Certified 01/26/2021 <br />Individuars signature: Date (rrFmlddlyyyy); <br />www.m.state.mn.us <br />wq-ww)sts4-38 • 1127117 <br />651-246.6300 • 800.657-3864 <br />. Lise your preferred relay service <br />Available in atternative formats <br />Page 3 of 3 <br />