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Property Address: yj <br />Business Name: <br />Z. Impact on public health — Compliance component #1 of 5 <br />Compliance criteria: Attached supporting documentation: <br />System discharges sewage to the ❑Yes~ ❑ No El Other: <br />ground surface <br />❑ Not applicable <br />System discharges sewage to drain ❑ Yes* ❑ No <br />the 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 />2. Tank integrity — Compliance component #2 of 5 <br />% -' <br />Compliance criteria: <br />Attached supporting documentation: <br />System consists of a seepage pit, <br />❑ Yes' a <br />❑ Empty tank(s) viewed by inspector <br />cesspool, drywell, leaching pit, <br />or other it? <br />Name of maintenance business: <br />Sewage tank(s) leak below their <br />❑ Yes' `VN0 <br />License number of maintenance business: <br />designed operating depth? <br />Date of maintenance: <br />❑ Existing tank integrity assessment (Attach) <br />Date of maintenance <br />If yes, which sewa a tanks leaks: <br />(mm/ddlyyyy): (must be within three years) <br />Any "yes" answer above indicates the system <br />(See form instructions to ensure assessment complies with <br />is failing to protect groundwater. <br />Minn. R. 7082, 0700 subp. 4 B (1)J <br />❑ Tank Is Noncompliant (pumping not necessary - explain below) <br />❑ Other: <br />Describe verification methods and results: f <br />//? D �. <br />Tanks pumped by: Kothrade Sewer, Water & E=xcavating, Inc„ Ll 92 <br />Licensed pumper: Larry Sursch, C9199 <br />Date:��� <br />https://www.pca.state.mn.us 651-296-6300 • 800.657-3864 • Use your preferred relays ervice, • Available in alternative formats <br />wq-svwists4-31b • 4/28/2023 Paye 2 of 4 <br />