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Property Address: 1 o y-,'0lii�L7tiz1 <br />Business Name: �� '; ] >� �n KX L Date: <br />l <br />1. Impact on public health — Compliance component 41 of 5 <br />Comniiance criteria - <br />System discharges sewage to the ❑ Yes* k) No <br />ground surface <br />System discharges sewage to drain ❑ Yes' H No <br />tile or surface waters. <br />System causes sewage backup into ❑ Yes' FMI 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 />Attached supporting documentation: <br />❑ Other: <br />❑ Not applicable <br />2. Tank integrity —Compliance component ##2 of 5 <br />Comnliance rritPria- <br />System consists of a seepage pit, ❑ Yes' ❑ Ne <br />cesspool, drywell, leaching pit, <br />or other pit? <br />Sewage tank(s) leak below their ❑ Yes" ❑ No <br />designed operating depth? <br />If yes, which sewage tanks) leaks: <br />Any "yes" answer above indicates the system <br />is failing to protect groundwater. <br />Describe verification methods and results: <br />S -��; q w € / <br />Attached supporting documentation: <br />❑ Empty tank(s) viewed by inspector <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): mm(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 />https://www.pca.state,mr.us 651-246-6300 800-657-3864 Use your preferred relay service Available in alternative formats <br />wq-wwists4-31b • 4/28/2021 Page 2 of 4 <br />