10-02-22 Septic Compliance Inspection

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CONROLMINNESOTA N�CY ON Sewage tank integrity assessment form 520 Lafayette Road North Subsurface Sewage St. Paul, MN 55155-4194 Treatment Systems (SSTS) Program Property address: %j Parcel 0 City State: _M �V. - Zip code: _ !�,C✓ 3 S ci I Purpose. This form may be used to certify the compliance status of the sewage tank components of the SSTS. This form is not a complete SSTS inspection report, only a tank integrity assessment, and may only certify sewage tank compliance status when entirely completed and signed by a qualified professional. SETS compliance inspection report forms can be found at: illttas.11wwvd�aca_state r!n.usl�vairlirrctiot�s. Instructions: This form may be completed, and signed, by a Designated Certified Individual (DCI) of a licensed SSTS inspection, maintenance, installation, or service provider business who personally conducts the necessary procedures to assess the compliance status of each sewage, tank in the system. A copy of this information should be submitted to the system owner and be maintained by the licensed SSTS business for a period of five (5) years from the assessment date. When this form is signed by a qualified certified professional, it becomes necessary supporting documentation to an Existing ! System Compliance Inspection Report: Comp ianca__torrr, w x._ t;=__et;q-vs +silts 31. This form can be found on l the M P C A website at h"�stais.mn, sltirirt�rlrns ctio , ! The information and certified statement on this form is required when existing septic tank compliance status is determined by an l individual other than the SSTS Inspector that submits an inspection report This form represents a third party assessment of SETS 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. l [Certificate of sewage tank compliance ❑ Notice of sewage tank non-compliance Affirm a I three statements: Select all that apply: The SETS does not contain a seepage pit, cesspool, ❑ The SSTS has a seepage pit, cesspool, drywell, drywell, leaching pit, or other pit. leaching pit, or other pit —"f=ailure to Protect [t __does not contain a sewage tank that was designed Groundwater." to be watertight, but subsequently leaks below the ❑ It has a sewage tank that was designed to be d ned operating depth, watertight, but subsequently leaks below the designed It does not represent an imminent safety threat by operating depth —"f=ailure to Protect Groundwater." reason of unsecured, damaged, or weak ❑ It presents a threat to public safety by reason of maintenance hole cover(s) or other unsafe condition. unsecured, damaged, or weak maintenance hole cover(s) or other unsafe condition -- w"Imminent Threat to Public Health or Safety." Company information Company name: _Duane's Septic Service Designated Certified Individual (DCI) information Print name: 1) 41 "1- ,V e _ ]'AZ Business license number: 654 _ _ Certification number cz.0 b'Lf I personally conducted the work described above as a Designated Certified Individual of a Minnesota -licensed SSTS inspection, maintenance, installation, orservice provider Business. 1 personally conducted the necessary procedures to assess the compliance status of each sewage tank in this SSTS. By typing/signing my name below, 1 certify the above statements to be true and correct, to the best of my knowledge, and that this information can be used for the purpose of processing this form. Designated Certified n Individual's signature: /�� Date (mmlddlyyyy): �— L [- Z 2 (This dacument has been electron�Iyned. j www.pca.state.mn,us 651-296-6340 800-557-3664 Use your preferred relay service Available in alternative formats wq-wwi5t54-91 • 115121 Page 1 of 1