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1. Impact on public health — Compliance component #1 of 5 <br /> Compliance criteria: Attached supporting documentation: <br /> System discharges sewage to the 0 Yes ® No ❑ Other: <br /> ground surface <br /> Z Not applicable <br /> System discharges sewage to drain 10 Yes ® No <br /> tile or surface waters. <br /> System causes sewage backup into 0 Yes' ®No <br /> dwelling or establishment. <br /> Any"yes"answer above indicates the system is an <br /> imminent threat topublic health and safety. <br /> Describe verification methods and results: <br /> Searched for surface outlet or ground discharge <br /> Checked for back-up <br /> 2. Tank integrity— Compliance component #2 of 5 <br /> Compliance criteria: Attached supporting documentation: <br /> System consists of a seepage pit, 0 Yes ®No 0 Pumped at time of inspection <br /> cesspool, drywell, leaching pit, <br /> or other pit? Name of maintenance business: Sewer Services <br /> Sewage tank(s)leak below their .0 Yes' ® No License number of maintenance business: 2502 <br /> designed operating depth? <br /> Date of maintenance: 4/14/2021 <br /> O 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 sub p. 4 B(1)) <br /> O Tank is Noncompliant(pumping not necessary—explain below) <br /> O Other: <br /> Describe verification methods and results: <br /> Pumped& Inspected <br /> https://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 al <br />