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3 S'gWp � <br />1. Impact on public health — Compliance component #1 of 5 <br />Compliance criteria: <br />System discharges sewage to the ❑ Yes" IN No <br />ground surface <br />System discharges sewage to drain ❑ Yes" W No <br />tile or surface waters. <br />System causes sewage backup into ❑ Yes' 11 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 />�VJ a C7 Ci 0a 'F i' yl� 4- Sc7) L U V 0�z— <br />2. Tank integrity — Compliance component #2 of 5 <br />Compliance criteria: <br />System consists of a seepage pit, ❑ Yes' [M No <br />cesspool, drywell, leaching pit, <br />or other pit? <br />Sewage tank(s) Peak below their ❑ Yes* W No <br />designed operating depth? <br />e tank(s) 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: S-p�C�S1t-► <br />License number of maintenance business: 3 g 14 <br />Gate of maintenance: <br />❑ Existing tank integrity assessment (Attach) <br />Date of maintenance <br />(mmlddlyyyy): (must be within three years) <br />(See form instructions to ensure assessment complies with <br />Minn. R. 7082.0700 subp. 4 B (7)) <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 Available in alternative formats <br />wq-wwrsts4-31b • 1111121 Page 2 of 4 <br />