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Property Address: S 0 >!�-V <br />Business Name: L Date: e) <br />1. Impact on public health — Compliance component #1 of 5 <br />Compliance criteria: <br />System discharges sewage to the I [:]Yes* 0 No <br />ground surface <br />System discharges sewage to drain ❑ Yes* 0 No <br />the nr ci irfnrc —f— <br />System causes sewage backup into ❑Ye2No <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 />Attached supporting documentation: <br />❑ Other: <br />® Not applicable <br />Z. Tank integrity — Compliance component #Z of 5 <br />Compliance criteria: <br />System consists of a seepage pit, <br />cesspool, drywell, leaching pit, <br />orother pit"? <br />Sewage tank(s) leak below their <br />designed operating depth? <br />❑ Yes` ❑ No <br />1' Yes" ❑ No <br />If yes, which sewage tanks) leaks: <br />Any "yes" answer above indicates the system <br />is failing to protect groundwater. <br />1411 4- a V,.,c? i t,.. - "4-,4 N1 `, <br />Describe verification methods 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 />(mmlddryyyy): (must be within three years) <br />(See form instructions to ensure assessment complies with <br />Minn- R. 7082.0700 subp. 4 B (7)) <br />❑ Tank is Noncornpiiant (pumping not necessary - explain below) <br />❑ other: <br />https://www.pca.state.rnn.u5 651-296-6300 800-657-3864 • Use your preferred relay service Available in alternative formats <br />wq-wwists4-31b • 412812021 Page 2 of 4 <br />