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2. Impact on public health — Compliance component #1 of 5 <br />Compliance criteria: <br />System discharges sewage to the ❑ Yes' <br />® No <br />ground surface <br />System discharges sewage to drain ❑ Yes" <br />® No <br />tile or surface waters. <br />System causes sewage backup into ❑ Yes" <br />® No <br />dwelling or establishment.. <br />na t we ,dicaUs ter:,., ao <br />u.: e .t,i rt, pct .ej. <br />Describe verification methods and results: <br />Searched for surface outlet or ground discharge <br />Checked for back-up <br />Attached supporting documentation: <br />❑ Other: <br />® Not applicable <br />2. Tank integrity — Compliance component #2 of 5 <br />Compliance criteria: <br />System consists of a seepage pit, ❑ Yes' ® No <br />cesspool, drywell, leaching pit, <br />or other pit? <br />Sewage tank(s) leak below their i❑ Yes ® No <br />designed operating depth? <br />If yes, which sewage tank(s) leaks <br />above <br />Describe verification methods and results: <br />Pumped & Inspected <br />Attached supporting documentation: <br />® Pumped at tirne of inspection <br />Name of maintenance business: Sewer Services <br />License number of maintenance business: 2502 <br />Date of maintenance: 5/16/2022 <br />❑ Existing tank integrity assessment (Attach) <br />Date of maintenance <br />(mm/dd/yyyy): (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.mn.us 651-296-6300 800-657-3864 Use your preferred relay service Available in alternative formats <br />wq-wwists4-31b o 1/21/21 Page 2 of 4 <br />