05/20/2020 Sewage tank compliance form

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Propyaddress; 2775 Deer Run Trail East (Jeffrey & Sandra Praus) Parcel ID: 04-117-23-13-QQ15 city: —Orono state. MN _ zip code:_ 55356 _. optional section: Sewage Tank Compliance Certification This form does not represent a complote system Inspection report and only certifies sewage tank compliance staM. Instructions: This section of the form may be completed and signed by a Designated Certified Individual (DCI) of a licensed SSTS Maintenance Business who personally conducts the necessary procedures to assess the compliance status of each sewage tank In the system. When this section of the form is signed by a qualified certified professional, Existing System Compliance Inspection Report: 9csnpiIMM ins ion_fon found on the MPCA website at htto 2AMffi oca state mn u�lwater/ssts-and Yrentamno to an hie form can be The information and certified statement on this form is required when existing septic tank compliance status Is determined by an Individual other than the SSTS Inspect that submits the inspection report. It represents a third party assessment of SSTS component compliance and is allowable under Minn. R. 7082.0700, subp. 4 Item (B) subitem (1). This form is valid for a period of three years beyond the signature date on this form unless a new evaluation is requested by the owner or owner's agent or is required according to local regulations. Additional Administrative Rule references for this activity can be found at Minn. R. 7082.0700, subp. 4 items B, C, and D; 7083.0730 Rem C. )% Certificate of sewage tank compliance Affirm all three statements: The SSTS does not contain a seepage pit, cesspool, drywell, leaching pit, or other pit. it does to be wartertlghntain a t, but subsegquuenily leak below bele tank that was the e designed operating depth, it does not represent an imminent safety threat by reason of unsecured, damaged, or weak maintenance hole cover(s) or other unsafe condition. Company Information Company name: Nbin's E:'qPtiq Pumrg, LLC_, Business license number. 3346 ❑ Notice of sewage tank non-compliance Select a8 that apply: The SSTS has a seepage pit, cesspool, drywell, leaching pit, or other pit. C] it has a sewage tank that was designed to be watertight, but subsequently leaks below the designed operating depth. ❑ It presents a threat to public safety by reason of unsecured, damaged, or weak maintenance hole cover(s) or other unsafe condition. Designated Certified individual (DCQ Information Print name: Peter Peterson Certification number: 9227 I personally conducted the work described above as a Designated Certified Individual of a M nnesota4kensed SSTS Maintenance Business. t personally conducted the vy procedures to assess the compliance status of each sewage tank in this SSTS: Designated Certified 05/20/2020 Individuals signature: Date (mmtd ditw): s www.pca.state.mn.us • 651-296.6300 • 800-657-3864 Use your preferred relay service • Available In rraLtemat �fowm� 3 w-wwlsts4.38 • 1127117