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4lu s6GS <br /> 1. Impact on public health — Compliance component #1 of 5 <br /> Com•liance criteria: Attached supporting documentation: <br /> System discharges sewage to the ❑Yes* ® No ❑ Other: <br /> ground surface <br /> ❑ Not applicable <br /> System discharges sewage to drain CI Yes' Q No <br /> tile or surface waters. <br /> System causes sewage backup into ❑Yes* in No <br /> dwelling or establishment. <br /> Any"yes"answer above indicates the system is an <br /> imminent threat to public health and safety. <br /> Describe verification methods and results: <br /> �G IV'6L-1A4 D <br /> 2. Tank integrity — Compliance component #2 of 5 <br /> Corn.liance criteria: Attached supporting documentation: <br /> System consists of a seepage pit, ❑Yes* ❑No ❑ Pumped at time of inspection <br /> cesspool,drywell, leaching pit, <br /> or other .it? Name of maintenance business: <br /> Sewage tank(s) leak below their ❑Yes* ❑ No License number of maintenance business: <br /> designed operating depth? <br /> Date of maintenance: <br /> ❑ Existing tank integrity assessment(Attach) <br /> Date of maintenance <br /> If yes,which sewage tank(s) leaks: (mm/dd/yyyy): (must be within three years) <br /> Any "yes"answer above indicates the system (See form instructions to ensure assessment complies with <br /> is failing to protect groundwater. Minn. R. 7082.0700 subp. 4 B (1)) <br /> ❑Tank is Noncompliant(pumping not necessary—explain below) <br /> El Other: <br /> Describe verification methods and results: <br /> haps://www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • Use your preferred relay service • Available in alternative formats <br /> wq-wwists4-31b • 1/11/21 Page 2 of 4 <br />