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1. Impact on public health — Compliance component #1 of 5 <br />Compliance criteria: Attached supporting documentation: <br />System discharges sewage to the ❑ Yes' ❑ No ❑ Other: <br />ground surface <br />❑ Not applicable <br />System discharges sewage to strain ❑ Yes' ❑ No <br />tile or surface waters. <br />System causes sewage backup into ❑ Yes' []No <br />dwelling or establishment. <br />Any "yes" answer above indicates the system is an <br />imminent threat to public health and safety. <br />Describe verification methods and results: <br />2. Tank integrity — Compliance component #2 of 5 <br />lance criteria_ <br />System consists of a seepage pit, ❑ Yes* DD. No <br />cesspool, drywell, leaching pit, <br />or other oit? <br />Sewage tank(s) leak below their ❑ Yes'�if�l0 <br />designed operating depth? /`� <br />If yes, which sewage tank(s) leaks: j <br />Any "yes" answer above indicates the system <br />is failing to protect groundwater. <br />Attached supporting documentation: <br />'i --pumped at time of inspection <br />r•� _ <br />Name of maintenance business:��L �n'C <br />License number of maintenance business: t 19? <br />Date of maintenance: <br />❑ Existing tank integrity assessment (Attach) <br />Hate of maintenance`" <br />(mmiddlyyyy): (must be within three years) <br />(See form instructions to ensure assessment complies with <br />Minn. R, 7082.0700 subp. 4 B (1)) <br />❑ Tank is Noncompliant (pumping not necessary --explain below) <br />❑ Other: <br />Describe verification methods and results: { ? , —7, ; <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 • 1/11/21 Page 2 of 4 <br />