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Property address: <br />City: Orono <br />2700 White Oak Circle Parcel ID: 0411723420021 <br />State: MN Zip code: 55356 <br />Optional section: Sewage Tank Compliance Certification <br />This form does not represent a complete system inspection report and only certifies sewage tank compliance status. <br />Instructions: This section of the form may be completed and signed by a Designated Certified Individual (DCI) of a licensed SSTS <br />Maintenance 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 becomes necessary supporting documentation to an <br />Existing System Compliance Inspection Report: Compliance inspection form - Existing system (wg-wwists4-31b). This form can be <br />found on the MPCA website at https://www.pca.state.mn.ustwater/ssts-and-msts-technical-and-compliance-criteria. <br />The information and certified statement on this form is required when existing septic tank compliance status is determined by an <br />individual other than the SSTS Inspector 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 (B) subitem (1). This form is valid for a period of <br />three years 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 Items B, C, and D; 7083.0730 Item C. <br />0 Certificate of sewage tank compliance <br />Affirm all three statements: <br />0 The SSTS does not contain a seepage pit, cesspool, <br />drywell, leaching pit, or other pit. <br />0 It does not contain a sewage tank that was designed <br />to be watertight, but subsequently leaks below the <br />designed operating depth. <br />0 It does not represent an imminent safety threat by <br />reason of unsecured, damaged, or weak <br />maintenance hole cover(s) or other unsafe condition. <br />Company information <br />Company name: Chip's Septic Services LLC <br />Business license number: 2064 <br />El Notice of sewage tank non-compliance <br />Select all that apply: <br />The SSTS has a seepage pit, cesspool, drywell, <br />leaching pit, or other pit —"Failure to Protect <br />Groundwater." <br />El It has a sewage tank that was designed to be <br />watertight, but subsequently leaks below the designed <br />operating depth —"Failure to Protect Groundwater." <br />El It presents a threat to public safety by reason of <br />unsecured, damaged, or weak maintenance hole <br />cover(s) or other unsafe condition —"Imminent Threat <br />to Public Health or Safety." <br />Designated Certified Individual (DCI) information <br />Print name: Pernel Chip Hentges <br />Certification number: <br />I personally conducted the work described above as a Designated Certified Individual of a Minnesota-licensed SSTS Maintenance <br />Business. I personally conducted the necessary procedures to assess the compliance status of each sewage tank in this SSTS: <br />Designated Certified <br />Individual's signature: Date (mnaidd/yyyy): if),' at,/ ecti <br />www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • Use your preferred relay service • Available in alternative formats <br />wq-wwists4-38 • 10/12/18 Page 3 of 3