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I. Impact on public health — Compliance Component #1 of 5 <br />Compliance criteria: <br />System discharges sewage to the ❑Yes* No <br />ground surface <br />System discharges sewage to drain ❑ Yes' ® 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 />Attached supporting documentation: <br />❑ Other: <br />❑ Not applicable <br />2. Tank integrity— Compliance component #2 of 5 <br />Compliance criteria: <br />System consists of a seepage pit, [:]Yes* ❑ No <br />cesspool, drywe[l, leaching pit, <br />or olher it? <br />Sewage tank(s) leak below their ❑ Yes* ❑ No <br />designed operating depth? <br />If which sewage tanks leaks: <br />Any "yes" answer above indicates the system <br />is failing to protect groundwater. <br />Describe verification methods and results: <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 />(mmlddiyyyy): (must be within three years) <br />(See form instructions to ensure assessment complies with <br />Minn. R. 7082.0700 subp. 4 8 (1)) <br />❑ Tank is Noncompliant (pumping not necessary- explain below) <br />❑ Other: <br />https://www.pca.state.mn.us - 651-236-6300 840-657-3864 Use your preferred relay service Available in alternative formats <br />wq-wwists4-31b • 1111121 Page 2 of 4 <br />