10-02-2021 - septic maintenance report

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Property address: _ 2675 Fox St Parcel ID: 0411723430003_ __ city: Orono state: MN -_- Zip code: 55391_ _ optional section: Sewage Tank Compliance Certification (Tank integrity assessment) This form does not represent a complete system inspection report and only certifies sewage tank compliance status. i.e., this form, completed, may serve as a tank integrity assessment. Instructions; This section of the form may be completed and signed by a Designated Certified Individual (DCI) of a licensed SSTS Maintenance Business who personally conducts the necessary procedures to assess the compliance status of each sewage tank in the system. When this section of the form is signed by a qualified certified professional, it becomes necessary supporting documentation to an Existing System Compliance Inspection Report: Compjiance in pection form Existing system (wg-vrwists4-31 b). This form can be found on the MPCA website at https:/Mww.pca.state.mn.ushvaterlservice-and-maintenance. The information and certified statement on this form is required when existing septic tank compliance status is determined by an individual other than the SSTS Inspector that submits an inspection report. This form represents a third party assessment of SSTS component compliance and is allowable under Minn. R. 7082.0700, subp. 4 Item (B) subitem (1). This form is valid for a period of three years beyond the signature date on this form unless a new evaluation is requested by the owner or owner's agent or is required according to local regulations. Additional Administrative Rule references for this activity can be found at Minn. R. 7082.0700, subp. 4 Items B, C, and D; 7083.0730 Item C. 0 Certificate of sewage tank compliance Affirm all three statements: $� The SSTS does not contain a seepage pit, cesspool, drywell, leaching pit, or other pit. It does not contain a sewage tank that was designed to be watertight, but subsequently leaks below the designed operating depth. ® It does not represent an imminent safety threat by reason of unsecured, damaged, or weak maintenance hole cover(s) or other unsafe condition. Company information Company name: Alb_i_n's Septic Pumping, LLC 3346 ❑ Notice of sewage tank non-compliance Select all that apply: [] The SSTS has a seepage pit, cesspool, drywell, leaching pit, or other pit — "Failure to Protect Groundwater." E] It has a sewage tank that was designed to be watertight, but subsequently leaks below the designed operating depth —"Failure to Protect Groundwater." [] It presents a threat to public safety by reason of unsecured, damaged, or weak maintenance hole cover(s) or other unsafe condition — "Imminent Threat to Public Health or Safety." Designated Certified Individual (DCI) information Print name: Peter Peterson _ Business lrcense number. Certification number: 9227 a _ 1 personally conducted the work described above as a Designated Certified Individual of a Mlnnesota4censed SSTS Maintenance Business. I personally conducted the necessary procedures to assess the compliance status of each sewage tank in this SSTS. By typingfsigning my name below, I certify the above. statements to be true and correct, to the best of my knowledge, and that this infonnedon can be used for the purpose of p ee sng�th' form. Designated Certified Individual's signature: Dye --- — — Date (mmlddlyyyy);_ 10/02/2021_ www.pca.state.mn.us • 651-296-6300 • BOD -657-3864 use your preferred relay service • Available in alternative formats wq-wMsts4-38 + 1/7/21 Page 3 of 3