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1. Impact on public health — Compliance component #1 of 5 <br />Compliance criteria: <br />._._.......... <br />System discharges sewage to the <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 />1"v"31,,> l <br />.,.? x d <br />o.'ti. t <br />_... _-. , <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: <br />System consists of a seepage pit, <br />cesspool, drywell, leaching pit, <br />or other1 1-11 pit? <br />Sewage tank(s) leak below their <br />designed operating depth? <br />❑ Yes, ® No <br />❑ Yes ® No <br />Ifyes, which sewage tanks) leaks: <br />{ ... t.,.. r,, . ab..,,( <br />Describe verification methods and results: <br />Pumped & Inspected <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: 2_502_ _ <br />Date of maintenance: 4/28/2022 <br />❑ Existing tank integrity assessment (Attach) <br />Date of maintenance <br />(mm/dd/ _____. <br />YYYY) (must hp �nith—-- <br />(See form instructions to ensure assessment complies with <br />Minn. R. 7082.0700 subp. 4 8 (9)) <br />❑ Tank is Noncompliant (pumping not necessary — explain below) <br />❑ Other: <br />ttps://www.pca.state.mn.us _ <br />651-296-6300 <br />800-657-3864 -- <br />Use your preferred relay service Available in alternative formats <br />wq-wwrsts4-316 1/11/21 <br />Page 2 of 4 <br />