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Property Address: �a -i 4 . <br />Business Name: - 4 ,� t u t r.. L <br />1. Impact on public heolth — Compliance component #1 of 5 <br />Compliance criteria: <br />System discharges sew, <br />ground surface <br />to the t ❑ Yes* 2 No <br />System discharges sewagle to drain❑Yes* D No <br />tile or surface waters. I <br />System causes sewage backup into ❑ Yes* F No <br />dwelling or establishment. <br />Any "yes" answer above indicates the system is an <br />imminent threat to Public health and safetv. <br />Describe verification methods and results: <br />Date: <br />Attached supporting documentation: <br />❑ Other: <br />❑ Not applicable <br />z. Tank integrity — Conjlpliance component #2 of 5 <br />I <br />Compliance criteria: <br />System consists of a seepage pit, <br />cesspool, drywell, leaching pit, <br />or other it? <br />Sewage tank(s) leak Belo their <br />designed operating depth;. <br />ff yes, which sewage to <br />Any "yes" answer <br />is failing to protect <br />❑ Yes* ❑ No <br />❑ Yes* ❑ No <br />indicates the system <br />dwater. <br />Describe verification m�thods and results: <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): (must be within three years) <br />(See form instructions to ensure assessment complies with <br />Minn. R. 7082.0700 subp. 4 B (l) ) <br />❑ Tank is Noncompliant (pumping not necessary —explain below) <br />❑ Other: <br />https://www.pca.state.rnn.us 6 1-296-6300 800-657-3864 Use your preferred relay service . Available in alternative formats <br />wq-wwists4-31b • 412 812 02 1 Page 2oja <br />