10-28-2021 Septic Compliance - Laserfiche WebLink

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Property address: 2575 Fox St _ . _ Parcel lo: 041172343f}Qfl3_ City: Orono --- _.. State: MN _ Zip rade: 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 statru& i.e., this form, completed, may serve as a tank integrity assessment. in ane: This section of the form may be completed and signed by a Designated Certified Individual (DCI) of a licensed SETS 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 cluaiified cer#ifred professional, R becomes necessary supporting docu wntatdon to an Existing System Compliance Inspection Report: Cgmpliance inspegfin form - Existing system (wq "ists4-31.b], This form can be found on the MPCA website at https:/hwww.pca.state.mn.uslwaterlserAoe-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 fort 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 0; 7083.0730 Item C. Ig 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. ❑ 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 Proted Groundm ter." © It has a sewage tank that was designed to be watertight, but subsequently leaks below the designed operating depth -"Failure to Protect Groundwater." Q It presents a threat to public safety by reason of unsecured, damaged, or weak maintenance hole coven(s) or other unsafe condition -"Imminent Threat to Public Health or Safety." Company Inforfnaf on Designated Certified Individual (DCI) Information Company name: Albin's Septic Pumping, LLC______ print name: Peter Peterson Business license number. 3346 - --- Certification number 9227 1 pe►sonadly conducted the worts described above as a Designated Certified Individual of a Mtnnesota-Abotised SSTS Maintenance Business. / personally conducted the necessary procedures to assess the compliance status ofeach sewage tank its MIS SSTS. By typh*wgn ft my name below. I certify the above statements to be true and correct, J0 o Mq best of my lu fledge, and that this tr:tbmiation can be used /or the purpose of p 1ngl,th' 1100. Designated Certified Individual's signature: % " _ _._ _ _ Date (mmlddtyyyy): 10/02/2021 _ vuww.pp.state.me.us 651-196 6304 804657-3864 use your preferred relay service Available in alternative formats wq-wwists438 0 I/ml Page 3 of 3