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Mike Gualtieri & Shawna Johnson parcel ID: 04-117-23-12-N17 <br />Property address: 2755 Countryside Drive West _ _ �_ _ <br />State _MN �p code: 55356 .. <br />City Orono _ �.. <br />optional section: Sewage Tank Compliance Certification <br />This form does not represent a complete system inspection report and only aerafles sewage tank compllance status. <br />dual <br />Instructions: This ss wh of the form may be <br />the necessnarrysprn�dures to assess the compliancted Certified e status ofleach sewage tan kin <br />Maintenance Business who personally Gond <br />the system. docurnantallon to an <br />When this section ofthe form Is signed by a qualified certified profeaslonai, it becomes necessary aupAor#int7 . This farm can be <br />Existing System Compliance Inspection Report 11 ec <br />found on the MPCA webalte at <br />The Information and certified statement on this form is inquired when existing septic tank compliances status <br />Isment r dined by an <br />Individual other than the SSTS inspector that submits the inspection report. It represents a third party <br />SSTS <br />component compliance and is allowable under Minn. R. 7082.070(1, subp. 4 ltion is eat (B) subitem (1). This form Is valid for a period of <br />three require years beyond rgthe signature regulations. date on this form unless a new Additions Administrative Rue references for theirs by <br />can be found at the owner or owner'sM nit or Is <br />required according to local <br />n. <br />R. 7082.0700, subp. 4 Items B, C, and 0; 7083.0730 Item C. <br />)ffi of ❑ Notice of sewage tank non-compliance <br />Certifies#e sewage tank compliance <br />Affirm all three statements: Select all that apply= <br />D4 The SSTs does not contain a seepage pit, cesspool, <br />'t ' <br />drywell, leaching pit, or other pit. <br />$t It does contain a sewage tank that was designed <br />to be watertight, but subsequently leaks below the <br />designed operating depth. <br />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 />❑ The SSTS has a seepage pr cesspool drywall, <br />, <br />leaching pit, or other pit, <br />It has a sewage tank that was designed to be <br />watertight, but subsequently leaks below the designed <br />7jtprresennt8dTt'hh�-9t to public safety by reason ofecured, damaged, or weak meintenar" hose <br />cover(s) or other unsafe condition. <br />Designated Certified individual (DCI) infotmatlon <br />Company natter: Allen's Se 'c��_�______ �.:. <br />Print name: Peter Peterson _— <br />Business license number: 3348 Certification number. R27 <br />1 pe►satallY cortducted the work described above as to assesnated s thcomplianceIndividual �tatusr of each sewage lank, in � sr SSTs: <br />Business. J Personally conducted the n ry procedures <br />Designated Certified Date (mm/ddlyyyy): _ 05/1912020 <br />individuars signature: <br />.._ <br />Available in attemativc formats <br />www.pca.state.mn.us • 651-296-6300 - sw-b57-3864 Use your preferred relay service <br />pop 3 of 3 <br />wq-ww1sts4.38 • 1127117 <br />