Laserfiche WebLink
Propedyedeiress: 40 Truffula Trail (Luis & Veronica ,Acosta) Parcel ID: 33-118-23-44-0035 <br />city: Orono _ ._ — State; M N _ _ zip oodr. _ 55358 <br />Optional section: Sewage Tank Compliance Certification <br />This form does not represent a cm mpkde system inspection report and only csttlfles swag* tank compliance nbkb a. <br />Instructlons. This section of the form may be completed and signed by a Designated Certified Individual (DCL) of a licensed SSTS <br />Meintr wwm Business who personally conducts the necessary procedures to assess the compliance status of each sewage tank in <br />the system. <br />When this section of the form is signed by a qualified certified professional, it taecortrres rre©essary supporting d0cument8ti n to an <br />Existing System Compliance Inspection Report: gdMplian< & inspggos�fo M- E�dstina system hNc jddjls4-B1 bl. This form can be <br />found on the MPCA website at'"'l U7ffi t:.>+ ,g ' state M0 us Qsrl ,sir ar►�j ^^ technical-and�aemnl- +tea. <br />The information and certified statement on this form Is required when eidsting septic tank compliance status is determined by an <br />individual other than the $STS Inspacw that submits the inspection report. It represents a third party assessment of SSTS <br />component compliance and is allowable under Minn. R. 7082.0700, subp 4 Item k3) subitem (1). This form is valid for a period of <br />three years beyond the signature date on this forth unless a new evaluation is requested by the owner or owner's agent or Is <br />required wording to local regulations_ Additional Administrative Rule references for this activity can be found at Minn. <br />R. 7082.070D, subp. 4 Items l3. G, and D7 7083.07W [tern v. <br />19 Certificate of sewatge tank ccamPliamce <br />Affirm all three statements: <br />Ig The SSTS does not contain a seepage pit, cessp Oi, <br />drywall, leaching pit, or other Pit. <br />It does not corftn a sewage tank that was designed <br />to be watertight, but subsequently Leaks below the <br />designed operating depth. <br />It does not represent ar irnrninent safely threat by <br />reason of unsecured. damaged, or weak <br />maintenance hole cover(s) or other unsafe condition. <br />Company information <br />Company name: Ailtan"s Septic Pump net, LLC <br />Business license number: 3345 — <br />0 Notice of sewage tank non-compliance <br />Select & that apply: <br />] The SETS has a seepage pit, cesspool, drywell, <br />leaching pit, or other pit. <br />p It has a sewage tank that was designed to be <br />watertight, but subsequently leaks below the designed <br />operating depth. <br />Q It presents a threat to public safety by reason of <br />unsecured, damaged. or week maintenance hole <br />cover(s) or other unsafe condition - <br />Designated Certified Individual (DCI) Inf6rn atlon <br />Print name: Peter Peterson_ — <br />Certification number: 9227 <br />l personaNyy conducted Noe work described above as a Designated Wffled lndMduaf of a Afirtnesotg4c ensed SSTSM$irtf&W= <br />Business. l personally conducted the no ry pmcedures to assess the crxnpNOnM stomia of each sta <br />ewage rns in this SSTS.- <br />Designated certified 0112612021 <br />Individual's signature: r beta (rnrnlddlYYYY) _ -- — <br />www,pca.Aate.mn.us • 55' 24f,.6= A 800.651-3864 lice your preferrea relay service Available in stternRO a formats <br />wq-ww1sts4-38 • 1127; 17 Page 3 of 3 <br />