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Property Address: 6!6__,LeAAC + <br />Business Name: 1-j \, i :,t L.. Date: l 7, <br />1. Impact on public health — Compliance component 41 of 5 <br />Compliance criteria: <br />System discharges sewage to the ❑ Yes* OW No <br />ground surface <br />System discharges sewage to drain ❑ Yes` 0 No <br />tile or surface waters. <br />System causes sewage backup into ❑ Yes* 10 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 />Attached supporting documentation: <br />❑ Other: <br />❑ Net applicable <br />2. Tank integrity — Compliance component #2 of 5 <br />Compliance criteria: <br />System consists of a seepage pit, ❑ Yes' ❑ No <br />cesspool, dryweil, leaching pit, <br />or other it? <br />Sewage tank(s) leak below their ❑ Yes' ❑ No <br />designed operating depth? <br />If ves. which <br />Any "yes" answer above indicates the system <br />is failing to protect groundwater. <br />Describe verification methods and results: <br />Attached supporting documentation: <br />❑ Empty tank(s) viewed by inspector <br />Name of maintenance business.- <br />License <br />usiness:License number of maintenance business: <br />Date of maintenance: <br />❑ Existing tank integrity assessment (Attach) <br />Date of maintenance <br />(mm/ddlyyyy): (must be within three years) <br />(See form instructions to ensure assessment complies with <br />Minn. R. 7082.0700 subp. 4 S (1)) <br />❑ Tank is Noncompliant (pumping not necessary—explain below) <br />❑ Other: <br />https://www.pca.state.rnn.us - 651-295-5300 800-657-3864 Use your preferred relay service Available in alternative formats <br />wq-wwists4 31b • 4/28/2021 Page 2 of 4 <br />