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Property address: 3625 Jacobs Mill Rd (Kurt & Carol Schmidt _ Parcel ID: 3211823240013 <br />r. <br />city: Orono state: MN _ zip node:_ 55356— <br />Optional section: Sewage Tank Compliance Certification <br />This faun does not represent a comploto aystern inspection report and only certifies sewage tank compliance status. <br />instructions: This section of the form may be completed and signed by a Designated Certified Individual (t3Cl) sof a licensed SSTS <br />Maintenance Business who personally conducts the necessary procedures to assess the compliance status of each sewage tank in <br />the system. <br />When this section of the form is signed by a qualified certified professional, it becomes necessary supporting docurnentafion to an <br />Existing System Compliance Inspection Repast: Compliance inapgdon form I~xW:lp�tem Lwq-%v&stAA:31 bl.This form can be <br />found on the MBCA website at httos:/Avww.oca.�t .mn.ushvaterlssts-and-mats-techri l- nd-com Il nce- ' eda. <br />The information and certified statement on this form is required when existing septic tank compliance status is determined by an <br />individual other than the SSTS Inspector that submits the Inspection report. It represents a third party assessment of SETS <br />component compliance and is allowable under Minn. R. 7082.0700, subp. 4 Item (B) subitem (1), This form Is valid for a period of <br />three years beyond the signature date on this form unless a new evaluation is requested by the owner or owner's agent or is <br />required according to local regulations. Additional Administrative Rule references for this activity can be found at Minn. <br />R. 7082.0700, subp. 4 Items B. C, and D: 7083,0730 Item C. <br />0 Certificate of sewage tank compliance <br />Affirm all three statements: <br />0 The SSTS does not contain a seepage pit, Cesspool, <br />drywall, leaching pit, or other pit. <br />It does not contain a sewage tank that was designed <br />to be watertight, but subsequently leaks below the <br />designed operating depth. <br />It does riot represent an imminent safety threat by <br />reason of unsecured, damaged, or weak <br />maintenance hole cover(s) or other unsafe condition. <br />[] Notice of sewage tank non-compliance <br />Select all that apply: <br />® The SETS has a seepage pit, cesspool, drywell, <br />leaching pit, or other pit. <br />❑ It has a sewage tank that was designed to be <br />watertight, but subsequently leaks below the designed <br />operating depth. <br />it presents a threat to public safety by reason of <br />unsecured, damaged, or weak maintenance hole <br />cover(s) or other unsafe condition. <br />Company information Designated Certified Individual (DCQ Information <br />Company Hama: AEbin's Septic Pumping, LLC Print name: Peter Peterson _ — <br />Business license number: 3346 —� Certification number: 9227, _ <br />I personalty conducted the work described above as a Designated CenSfred Individual of a Minnesota-ticensed SSTS Maintenance <br />Business. 1 personally conducted the n s ry procedures to assess the compliance status of each sewa{}e tank in this SSTS; <br />Designated Certified 10/2412020 <br />Individual's signature: ' — mate (mmldd/yyyy): — <br />www.pca.state.mmus • 651-296-6300 80t]-657-3864 Use your preferred retay service Available in alternative formats <br />Page 3 of 3 <br />wq-ww1sts4.38 • 1127117 <br />