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1. Impact on public health — Compliance component #1 of 5 <br />Compliance criteria: <br />Attached supporting documentation: <br />System discharges sewage to the ❑ Yes' ®No <br />❑ Other: <br />ground surface <br />- - --, <br />_---.._ __ __ <br />® Not applicable <br />System discharges sewage to drain ❑ Yes* ® No <br />'.. <br />tile or surface waters. <br />System causes sewage backup into []Yes* ® No <br />dwelling or establishment________ <br />Any "yes" answer above indicates tjre system is an <br />'.. <br />_ imminent threat to Public health and safety - <br />Describe verification methods and results: <br />Searched for surface outlet or ground discharge <br />Checked for back-up <br />2. Tank integrity— Compliance component #2 of 5 <br />Compliance criteria: Attached supporting documentation: <br />System consists of a seepage pit, ELI Yes' ® No ® Pumped at time of inspection <br />cesspool, drywell, leaching pit, - <br />Sewage tank(s) leak below their []Yes* ® No <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 />Pumped & Inspected <br />Name of maintenance business: Sewer Services <br />License number of maintenance business: 2502 <br />Date of maintenance: _2_/_16_/_20.22 <br />❑ Existing tank integrity assessment (Attach) <br />Date of maintenance <br />(mm/ddiyyyy): (must bi 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 • 1/11/21 <br />P"ge 2 cf4 <br />