11-20-2022 Septic Compliance Inspection Report

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M MINNISOIAA PQil ;tt+ON CONTROL Sewage tank integrity assessment form CONF .•' u! iWrrr WJE i AliNt'+ Subsurface Sewage Rit i''y "i,"i y' Treatment Systems (SSTS) Program Prop.rty aiiiar=a City - Purpose: This fCrin may be to ck�rtity the compliance status of the sewage tank components of the SSTS This form is not a compleb SSTS inspection report, only a tank integrity assessment, and may only certify sewage tank comptiance status when entirely completed and signed by a qualified professional. SSTS compliance inspection report forms can be found at Instructions: This form may be completed, and signed• by a Designated Certified Individual (DCI) of a licensed SSTS inspection maintenance. Installation, or sennce provider business who personally conducts the necessary procedures to assess the compliance status of each sewage tank in the system A copy of this inkmation 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 st44por6np documentation to an Existing System Compliance inspection Report This form can be found on the MPCA website at P rvp , - 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 parry assessment of SSTS component compliance and is allowable under Minn R 7062.0700 subp 4 Item (B) subitem (t). 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 of is required according to local regulations Additional Administrative Rule references for this activity can be found at Minn R 7082.0710. subp 4 Items B. C. and D. 7083 0730 Item C 7� Certificate of sewage tank compliance Affirm all three statements The SSTS does not contain a seepage pit. cesspool, dryweil, 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 Notica of sewage tank non-compliance Select ail that apply ❑ The SSTS has a seepage pit• cesspool, drywelf 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) of other unsafe condition w1mminent Threat to Public Health or Safety.' Company information Designated Certified Individuai (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 Cert flied Individual of a Allinnesata-hcensed SSTS rnswc1m maintenance installadon, or service provider Business f personally condWed the necessary procedures to assess lire comphance status of eactr sewage tank in this SSTS By typinoigning my mune below. 1 certify the above statemepts to be true and correctto the best of my knowledge, and that this infurrrration can be used for the purpose ofprocessing r9trs form Designated Certified individual's signature: Date (mmlddlyyyy): (This doc xnent has Bean el6cfrpniceNy &geed , www mi. state Mn.sn bs r.lay w1,)0 800-657 3664 use your pnitrred n"V +trace 4vaiabie'n aitemame f0muIS wv wwesLsd-97 + !/5/21 Frage t aft