05/07/2021 Compliance Inspection Report

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MINNESOTApQLYYflaw 631 CONTROL AGENCYSewage tank integrity assessment form 520 Lafayette Road North Subsurface Sewage 5t. Paul, MN 55155-4194 Treatment Systems (SSTS) Program Property address: P? 9 0 F0 X 57, Parcel ID: City: J to ; AIT ai State: M 6 I Zip code: Purpose. This form may be used to certify the compliance status of the sewage tank components of the SSTS. This form is not a complete SSTS inspection report, only a tank integrity assessment, and may only certify sewage tank compliance status when entirely completed and signed by a qualified professional. SSTS compliance inspection report forms can be found at: htt s:J/www. r.a.state.mn.us/watgrFfs pec#ions. Instructions! This form may be completed, and signed, by a Designated Certified Individual (RGI) of a licensed SSTS inspection, maintenance, installation, or service provider business who personally conducts the necessary procedures to assess the compliance status of each sewage tank in the system. A copy of this information should be submitted to the system owner and be maintained by the licensed SSTS business fora period of five (5) years from the assessment date. When this form is signed by a qualified certified professional, it becomes necessary supporting documentation to an Existing System Compliance Inspection Report: Comlance inspection form - Existin sustem(vuq-w+Jsts4-31b,. This form can be found on the MPGA website at https://www.pca..s!ate.Mn.us/wetarlin p.otic)ns. The information and certified statement on this form is required when existing septic tank compliance status is determined by an individual other than the SSTS Inspector that submits an inspection report. This form represents a third party assessment of SSTS component compliance and is allowable under Minn. R. 7082.0700, subp. 4 Item (B) subitem (1). This form is valid for a period of three years beyond the signature date on this form unless a new evaluation is requested by the owner or owner's agent or is required according to local regulations. Additional Administrative Rule references for this activity can be found at Minn. R. 7082.0700, subp. 4 Items B, C, and D; 7083.0734 Item C. M --Certificate of sewage tank compliance Affix' ll three statements: U The,SSTS does not contain a seepage pit, cesspool, irywell, leaching pit, or other pit. M It does not contain a sewage tank that was designed to be watertight, but subsequently leaks below the esigned operating depth. It does not represent an imminent safety threat by reason of unsecured, damaged, or weak maintenance hole cover(s) or other unsafe condition. Company information Company name: Duane's Septic Service Business license number: 654 ❑ Notice of sewage tank non-compliance Select ail that apply: Cl The SSTS has a seepage pit, cesspool, drywelf, leaching pit, or other pit — "Failure to Protect Groundwater." ❑ It has a sewage tank that was designed to be watertight, but subsequently leaks below the designed operating depth — "Failure to protect Groundwater:' Q it presents a threat to public safety by reason of unsecured, damaged, or weak maintenance hole cover(s) or other unsafe condition — w"Imminent Threat to Public Health or Safety." Designated Certified Individual (DCI) information �Ic. Print name: �Y t J� Certification number: ' -' i I personally conducted the work described above as a Designated Certified Individual of a Minnesota -licensed SSTS inspection, maintenance, installation, or service provider Business. I personally conducted the necessary procedures to assess the compliance status of each sewage tank in this SSTS- By typing1signing my name below, I certify the above statements to be true and correct, to the best of my knowledge, and that this information can be used for the purpose of processing this farm. Designated Certified _A Individual's signature: '~ tom,_ Date(mmidd/yyyy): �L,' ; ,�(,�� (Thisocument has been electronically signed.) www.pca.state.mn.us 651-246-5300 800-657-3864 Use your preferred relay service Available In alternative formats wq-wwists4-91 + 115/21 Page 1 of 2