10-13-2021 Septic Compliance Inspection

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MINNESOTA POLLUTION CONTROL AGENCY Sewage tank integrity assessment form 520 Lafayette Road North Subsurface Sewage St. Paul, MN 55155-4194 Treatment Systems (SSTS) Program Doc Type: Compliance and Enforcement Purpose: This form may be used to certify the compliance status of the sewage tank components of the SSTS. This form isnot a complete SSTS Inspection report, only a tank integrity assessment, and may only certify sewage tank compliance status when entirely completed and signed by a qualified professional. SSTS compliance inspection report forms can be found at: haps.,//www oca state mn ustwater/inspections. Instructions: This form may be completed, and signed, by a Designated CertifiedIndividuai (DCI) of a licensed SSTS inspection, maintenance, installation, or service provider business who personally conducts the necessary procedures to assess the compliance status of each sewage tank in the system. Only a licensed maintenance business is authorized to pump the tank for assessment. A copy of this information should be submitted to the system owner and be maintained by the licensed SSTS business for a period of five (5) years from the assessment date. When this form is signed by a qualified certified professional, it becomes necessary suppordng documentation to an Existing System Compliance Inspection Report: Compliance insoection form - Existing system (coq wwists4-31 b). This form can be found on the MPCA website at httos://www.oca.state.mn.ustwaterfinspections. 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(B)(1). This form is valid for 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(8),(C), and (D) and; Minn. R. 7083.0730(C). Owner Property address: L2M Local Regulatory Authority: status Parcel ID: Systems atus on date (mmlddlyyyy): /L1Q;4 _ Certificate of sewage tank Wompliance ❑ Notice of sewage tank non-compliance Compliance criteria: The SSTS has a seepage pit, cesspool, drywell, leaching pit, or other pit - "Failure to Protect Groundwater." ❑ Yes* ( No The SSTS has a sewage tank that leaks below the designed operating depth - "Failure to Protect I [--]Yes* 0 No Groundwater." The SSTS presents a threat to public safety by reason of structurally unsound (damaged, cracked, or weak) maintenance hole cover(s) or lids or any other unsafe condition - "imminent Threat to ❑ Yes" No Public Health or Safety." Any "yes" answer above Indicates sewage tank non-compliance. Company infor Icil do Designated fortified In ividual (PCI) information Company name: (,Print name: _ Business license number: Certification number: I personally conducted the work described above as a Designated Certified individual of a Minnesota-lice»sed SSTS Inspection, maintenance, installation, orserviee provider Business. i personally conducted the necessary procedures to assess the compliance status of each sewage tank In this SSTS. By typinoigning my name below, i certify the above statements to be true and correct, to the best of my knowledge, and that this information can be used for the purpose of processing 1,W form. Designated Certified Individual's signature: Date (mm/dd/yyyy): D ' fs doCume -ha. baan electronfeeliysigned.) www.pca.state.mn.us • 651-296-6300 800-657-8864 • Use your preferred relay service 0 Available in alternative formats coq--itts4.91' • 5110121 Page 2 of 1