08/15/2022 Septic Maintenance Report

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Property address: 1300 French Creek Drive (Deborah Hopp) Parcel ID: 1011723230004 _ City: Orono stem: __MN— _ zip code:55391_ Optional section: Sewage Tank Compliance Certification This form does not represent a complete system inspection report and only certifies sewage tank compliance status. Instructions: This section of the form may be completed and signed by a Designated Certified Individual (DCI) of a licensed SSTS Maintenance Business who personally conducts the necessary procedures to assess the compliance status of each sewage tank in the system. When this section of the form is signed by a qualified certified professional, it becomes necessary supporting documentation to an Existing System Compliance Inspection Report: ComoIlan ce inspection form Existing system Lv6M_vOvist 4:=. This form can be found on the IVIPCA website at h d/vuww oca state mn us/water/sets-and-mats-technical-and-cemgliance-criteria. The lnformation 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 the inspection report. It represents a third party assessment of SSTS component compliance and is allowable under Minn. R. 7082.0700, subp. 4 Item (B) subitem (1). 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. B( Certificate of sewage tank compliance Affirm all three statements: N The SSTS does not contain a seepage pit, cesspool, drywell, leaching pit, or other pit. it does not contain a sewage tank that was designed to be watertight, but subsequently leaks below the designed 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 Select all that apply: ❑ The SSTS has a seepage pit, cesspool, drywell, leaching pit, or other pit. ❑ It has a sewage tank that was designed to be watertight, but subsequently leaks below the designed operating depth. ❑ It presents a threat to public safety by reason of unsecured, damaged, or weak maintenance hole cover(s) or other unsafe condition. Company information Designated Certified Individual (DCI) Information Company name: Albirfs Septic Pumping, LLC Print name: Peter Peterson _ _ — Business license number: 3346_.__. Certification number: 9227 _ . I personally conducted the work described above as a Designated Certified Individual of a Minnesota4censed SSTS Maintenance Business. I personally conducted t,73ry procedures to assess the compliance status of each sewage tank in this SSTS: Designated Certified 08/15/2022 Individuars signature: Date (mmldd/yyyy): _ _. www.pca.state.mn.us • wq-wwists4.38 • 1127117 651-296-6300 • 800-657-3864 . Use your preferred relay serAX Available in alternative formats Page 3 of 3