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1. Impact on public health — Compliance component #1 of 5 <br />Compliance criteria; <br />System discharges sewage to the ❑ Yes' ITS No <br />ground surface <br />System discharges sewage to drain ❑ Yes' 0' No <br />the or surface waters. <br />System causes sewage backup into ❑ Yes' 9 No <br />dwellinq or establishment_ <br />Any "yes" answer above indicates the system is an <br />imminent threat to public health and safef . <br />Describe verification methods and results: <br />Attached supporting documentation: <br />❑ Other: <br />0 Not applicable <br />__lam _�°" i �'tc• , J"�__...�✓'� 4 � � <br />2. Tank integrity— Compliance component #Z of 5- -` <br />Compliance criteria: <br />System consists of a seepage pit, ❑ Yes" ❑ No <br />cesspool, drywall, leaching pit, <br />or other it? <br />Sewage tank(s) leak below their ❑ Yes` ❑ Na <br />designed operating depth? <br />If yes. which sewage 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: <br />License number of maintenance business: <br />Date 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 8 (1)) <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-wwists4-31b • 1111/23 Page2ofq <br />