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I. impact on public health — Compliance component #1 of 5 <br />Compliance criteria: <br />System discharges sewage to the16� <br />YNo <br />ground surface <br />System discharges sewage to drain I ❑ Yes` FFM No <br />System causes sewage backup into ❑ Yes` 0 No <br />dwelling ar establishment. <br />Any "yes" answer above indicates the system is an <br />imminent threat to public health and safety- <br />Describe <br />afety Describe verification methods and results: <br />Attached supporting documentation-, <br />❑ Other: <br />❑ Not applicable <br />2. Tank integrity — Compliance component #2 of 5 <br />nce criteria: <br />System consists of a seepage pit, ❑ Yes" ❑ No <br />cesspool, drywell, leaching pit, <br />or other pit? <br />Sewage tank(s) leak below their ❑ 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 />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 />(mmiddlyyyy), (must be within three years) <br />(See form instructions to ensure assessment complies with <br />Minn. R. 7082.0700 subp. 4 B (9)) <br />❑ Tank is Noncompliant (pumping not necessary— explain below) <br />❑ Other: <br />https://www.pca,state.mn.us 651-296-6300 800-657-3864 • use your preferred relay service Avai#able in alternative formats <br />wq-wwists4-31b • 1111121 Page 2 of 4 <br />