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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 ❑ Yes* ® No ❑ other: <br />ground surface <br />�. ® Not applicable <br />System discharges sewage to drain ❑ Yes* ® No <br />tile or surface waters. <br />System causes sewage backup into [:]Yes* ® 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 />Searched area <br />2. Tank integrity — Compliance component #2 of 5 <br />Compliance criteria: <br />System consists of a seepage pit, ❑ Yes* ® No <br />cesspool, drywell, leaching pit, <br />or other Tit? <br />Sewage tank(s) leak below their IE Yes* ❑ No <br />designed operating depth? <br />If yes, which sewage tanks leaks: <br />Any "yes" answer above indicates the system <br />is failing to protect groundwater. <br />Attached supporting documentation: <br />❑ Pumped at time of inspection <br />Name of maintenance business: <br />License number of maintenance business: <br />Date of maintenance: <br />❑ Existing tank integrity assessment (Attach) <br />Date of maintenance <br />(mmldd/yyyy): (must be within three years) <br />(See form instructions to ensure assessment complies with <br />Minn. R. 7082.0700 subp. 4 B (1)) <br />❑ Tank is Noncompliant (pumping not necessary - explain below) <br />❑ Other: <br />Describe verification methods and results: <br />The tanks were pmped by Elmer J. Peterson Company. See attached report. <br />https://www.pca.state.mn.us • 651-296-6300 • 800-657-3864 Use your preferred relay service Available in alternative formats <br />wq-wwrsts4-31b • 1/11/21 Poge2 of4 <br />