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Property address: �2 & l V r3 ? cr- ie., <br />City: <br />D ro Ac) <br />State: M <br />Parcel ID: <br />Zip code: Si <br />3:570 <br />Optional section: Sewage Tank Compliance Certification <br />This form does not represent a complete system inspection report and only certifies sewage tank compliance status. <br />Instructions: This section of the form may be completed and signed by a Designated Certified Individual (DCI) of a licensed SSTS <br />Maintenance Business who personally conducts the necessary procedures to assess the compliance status of each sewage tank in <br />the system, <br />When this section of the form is signed by a qualified certified professional, it becomes necessary supporting documentation to an <br />Existing System Compliance Inspection Report: Compliance inspection form - Existing system (wq-wwists4 31 b). This form can be <br />found on the MPCA website at httos://www.t)ca..state,mn.us/water/ssts-and-msts-technical-and compliance criteria. <br />The information and certified statement on this form is required when existing septic tank compliance status is determined by an <br />individual other than the SSTS Inspector that submits the inspection report. It represents a third party assessment of SSTS <br />component compliance and is allowable under Minn. R. 7082.0700, subp. 4 Item (B) subitem (1). This form is valid for a period of <br />three years beyond the signature date on this form unless a new evaluation is requested by the owner or owner's agent or Is <br />required according to local regulations. Additional Administrative Rule references for this activity can be found at Minn. <br />R. 7082.0700, subp. 4 Items B, C, and D; 7083.0730 Item C. <br />ertificate of sewage tank compliance ❑ Notice of sewage tank non-compliance <br />Affirmail ree statements: <br />O'The SSTS does not contain a seepage pit, cesspool, <br />ell, leaching pit, or other pit. <br />It does not contain a sewage tank that was designed <br />to be watertight, but subsequently leaks below the <br />9sigrfed operating depth. <br />Olt does not represent an imminent safety threat by <br />reason of unsecured, damaged, or weak <br />maintenance hole covers) or other unsafe condition. <br />Company information <br />Company name: Duane's Septic Service <br />Business license number: 654 <br />Select all that apply: <br />❑ The SSTS has a seepage pit, cesspool, drywell, <br />leaching pit, or other pit. } <br />Q It has a sewage tank that was designed to be <br />watertight, but subsequently leaks below the designed <br />operating depth. <br />❑ It presents a threat to public safety by reason of <br />unsecured, damaged, or weak maintenance hole <br />covers) or other unsafe condition. j <br />Designated Certified Individual (DCI) information <br />Print name: ) /� lc;✓' <br />Certification number: C2084 <br />/persona//y conducted the work described above as a Designated CertifiedIndividual of Minnesota -licensed SSTS Maintenance <br />Business. / personally conducted cessary procedures to assess the compliance status of each sewage tank In this SSTS. <br />Designated Certified <br />Individual's signature: Date (mm/dd/yyyy): <br />www.pca.state.mn.us • 651-296-6300 800-657-3864 <br />wq-wwists4-38 • 1127117 <br />Use your preferred relay service Available in alternative formats <br />Poo I of 7 <br />