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Property Address: <br />Business Name: S 11-1 !A L <br />I. Impact on public health — Compliance component #1 of 5 <br />Compliance criteria: <br />System discharges sewage to the <br />ground surface <br />Yes" lit No <br />System discharges sewage to drain ❑ Yes* M No <br />tile or surface waters <br />System causes sewage backup into ❑ Yes" R] No <br />dwelling or establishment. <br />Any "Yes" answer above indicates the system is an <br />imminent threat to public health and safety✓. <br />Describe verification methods and results: <br />Date: 9 - _"- <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, <br />cesspool, drywell, leaching pit, <br />or other pit? <br />Sewage tank(s) leak below their <br />designed operating depth? <br />EJ Yes* Q No <br />❑ Yes* IM No <br />I rYC �J3u�L <br />If which sewage tang( ), leaks: <br />Any "yes" answer above indicates the system <br />is failing to protect groundwater. <br />.., -1�Irl <br />Attached supporting documentation: <br />H Empty tank(s) viewed by inspector <br />Name of maintenance business: <br />License number of maintenance business: 'Z,i,} <br />Date of maintenance: <br />❑ Existing tank integrity assessment (Attach) <br />Date of maintenance <br />(mmlddiyyyy): (must be within three years) T <br />(See form instructions to ensure assessment complies with <br />Minn. R. 7082.0700 subp. 4 8 (1)) <br />❑ Tark is Noncompliant (pumping not necessary -explain below) <br />❑ other: <br />Describe verification methods and results: <br />'t° r ' . ,� r'�•`,..'� � 'L�`is A'�.k. � � 5.� �i+�1'~d a� � 5 uo � ®t Cu � t.��r -C� �+,` 4 u �t`�u.� <br />https:H-ww.pca-state.mn.us 651-296-6300 800-657-3864 use your preferred relay S <br />wq-wwists4-31b • 412512021 ervice Available in alternative Formats <br />Poge 2 of 4 <br />