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MINNESOTA SOTA PO5?. k tON CON'pROL AC-RENC- 520 Lafayette Road North 5t. Paul, MN 55155-4194 Sewage tank integrity assessment form Property address: `�� "V'� T City: 0 State: Subsurface Sewage Treatment Systems (SSTS) Program ParcelOi _ Zip code Purpose: This form may be used to certify the compliance status of the sewage tank components of the SSTS. This form is not a complete SSTS inspection report, only a tank integrity assessment, and may only certify sewage tank compliance status when entirely completed and signed by a qualified professional. SSTS compliance inspection report forms can be found at: iMr" j)s1/www.pca state. m#1_ush"JateLlIii G'cti�si5. Instructions: This form may be completed, and signed, by a designated Certified Individual (DCI) of a licensed SSTS inspection, maintenance, installation, or service provider business who personally conducts the necessary procedures to assess the compliance status of each sewage tank in the system. A copy of this information should be submitted to the system owner and be maintained by the licensed SSTS business for a period of five (5) years from the assessment date. When this form is signed by a qualified certified professional, it becomes necessary supporting documentation to an Existing System Compliance Inspection Report: Com .pfiance inspcVan for , - xi;tii�ctcrT r fy-vratists4 3?l�'i. This form can be found on the MPGA website at tames ll�v�rv_ti�t cawst�a:.r7r�.t�si�masringet€_,. The information and certified statement on this form is required when existing septic tank compliance status is determined by an individual other than the SSTS Inspector that submits an inspection report. This form represents a third party assessment of SSTS component compliance and is allowable under Minn. R. 7082.0700, subp. 4 Item (B) subitem (f). This form is valid for a period of three years beyond the signature date on this form unless a new evaluation is requested by the owner or owner's agent or is required according to local regulations. Additional Administrative Rule references for this activity can be found at Minn. R. 7082.0700, subp. 4 Items B, C, and D; 7083.0730 Item C. Certificate of sewage tank compliance Affirrn,,ail three statements: The SSTS does not contain a seepage pit, cesspool, Ar�w-ell, leaching pit, or other pit. It does not contain a sewage tank that was designed to be watertight, but subsequently leans below the signed operating depth. It does not represent an imminent safety threat by reason of unsecured, damaged, or weak maintenance hole cover(s) or other unsafe condition. ❑ Notice of sewage tank non-compliance — 12-50 -s l oA, ►1 k Le– Select all that apply: ❑ The SSTS has a seepage pit, cesspool, drywell, leaching pit, or other pit — "Failure to Protect Groundwater." ❑ It has a sewage tank that was designed to be watertight, but subsequently leaks below the designed operating depth — "Failure to Protect Groundwater." ❑ It presents a threat to public safety by reason of unsecured, damaged, or weak maintenance hole cover(s) or other unsafe condition — w"Imminent Threat to Public Health or Safety." CO k; e r,' Company information Designated Certified Individual (DCI) information Company name: Duane's Septic Service _ Print name: •�} t✓1ti! C1 Business license number: 654 Certification number: b 1-7 I personally conducted the work described above as a Designated Certified Individual of a Minnesota -licensed SSTS inspection, maintenance, installation, or service provider Business. 1 personally conducted the necessary procedures to assess the compliance status of each sewage tank in this SSTS. By typing/signing my .name below, 1 certify the above statements to be true and correct, to the best of my knowledge, and that this information can be used for the purpose of processing this form. Designated Certified C-- Individual's signature: �� Date (mmidd/yyyy): o A. 3 (T s document has been electronically signed.) www. pca,state. m n, us wq-wwists4-91 • 1/5/21 • 651-296-6300 800-657-3864 Use your preferred relay service • Available to alternative formats Page 1 of 1