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33"s &r-n-bao,7 Oi'l I 8, 6rbno ii1v <br />1. Impact on public health — Compliance component #1 of 5 <br />Com liance 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* ❑ No <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 />........................ _ <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, <br />cesspool, dryweil, leaching pit, <br />or other pit? <br />Sewage tank(s) leak below their <br />designed operating depth? <br />Yes' <br />Attached supporting documentation: <br />,No ❑ Pumped at time of inspection <br />(1 <br />Name of maintenance business:DO) <br />El <br />El Yes* (�rNo License number of maintenance business: V � `l <br />Date of maintenance: <br />❑ Existing tank integrity assessment (Attach) <br />Date of maintenance <br />(mm/ddtyyyy): (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 />Describe verification methods and results: <br />❑ Tank Is Noncompliant (pumping not necessary—explain below) <br />❑ Other: <br />tt,"VAP-ed OLA -ta,V4r 3... U00 3 tt/toil/ <br />https,//www.pca.state.mn.us 651-296-6300 800-657-3864 Use your preferred relay service • Available in alternative formats <br />wq-ww1sts4-31b • 1/11/21 Poge 2 of 4 <br />