11-04-22 Septic Compliance Report

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MINNESOTA POLLUTION CONTROL AGENCY 520 Lafayette Road North St. Paul, MN 55155-4194 Property address- 4 00 D City /Vt% UL� Sewage tank integrity assessment form .t 6a r P. L, V r• State: Subsurface Sewage Treatment Systems (SSTS) Program Parcel ID:_ — Zip code: 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. SSTS compliance inspection report forms can be found at: liltp3.l/wwW. Ca 5t2.tE mQ_yS14VdtL–'jliri5 eCtipli5. 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: Com liance inspeaPp.. fo rfc - Exi;t rc s stere (v1q-viwists4- 11. , This form can be found on the MPCA website at h s./hy� v� aca.astale.rLn sivrraterJir?s ectio . The information 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 an inspection report. This form 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 thfs activity can be found at Minn. R. 7082.0700, subp. 4 Items B, C, and D; 7083.0730 Item C. Certificate of sewage tank compliance Affirmree statements: The SSTS does not contain a seepage pit, cesspool, d leaching pit, or other pit. does not contain a sewage tank that was designed to be watertight, but subsequently teaks below the cl ed operating depth, E?Tdoes 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 — "Failure to Protect Groundwater." ❑ It has a sewage tank that was designed to be watertight, but subsequently leaks below the designed operating depth – "Failure to Protect Groundwater." ❑ It presents a threat to public safety by reason of unsecured, damaged, or weak maintenance hole cover(s) or other unsafe condition – w"Imminent Threat to Public Health or Safety." Company information Designated Certified Individual (DCI) information Company name: _Duane's Septic Service Print name:) Business license number: 654 _ _ Certification number: I personally conducted the work described above as a Designated Certified Individual of a Minnesota -licensed SSTS inspection, maintenance, installation, or service provider Business. l personatly 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 f he purpose of processing this form. Designated Certified Individual's signature: Date (mmlddlyyyy): /b ZC9 2Z (T is document has an electronically signed.] --- " www.pca.state.mn.us • 651-295-5300 • 800-657-3864 Use your preferred repay service Available in alternative formats wq-wwists4-91 • 115/21 Page 1 of 1