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1. Impact on public health — Compliance component #1 of 5 <br />Compliance criteria: <br />System discharges sewage to the ❑ Yes`, ® No <br />ground surface <br />System discharges sewage to drain ❑ Yes" ®No <br />tile or surface waters. <br />System causes sewage backup into ❑ Yes` ® No <br />dwelling or establishment. <br />V <br />"Vos , rtsvi x , <br />lr.<..,z ,,?'c 1 H? t - <br />�C- o -- <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 />Hance criteria: <br />System consists of a seepage pit <br />cesspool, drywell, leaching pit, <br />or other pit? <br />Sewage tank(s) leak below their <br />designed operating depth? <br />If yes, which sewage tank(s) leaks: <br />i.r.,� z arot" u.„ <br />■ � . <br />O - ■ <br />Describe verification methods and results: <br />Pumped & Inspected <br />https://www.pca.state.m n. us 651-296-6300 <br />wq-wwists4-31b • 1/11/21 <br />• 800-657-3864 <br />Attached supporting documentation: <br />❑ Other: <br />® Not applicable <br />Attached supporting documentation: <br />® Pumped at time of inspection <br />Name of maintenance business: Sewer Services_ <br />License number of maintenance business: 2502 <br />Date of maintenance: 4/21/2022 <br />❑ Existing tank integrity assessment (Attach) <br />Date of maintenance <br />(mm/dd/— <br />YYYY): (must be _ — <br />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 />Use your preferred relay service Available in alternative formats <br />Page 2 of 4 <br />