4-26-2023 - compliance certification

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Property address: 4300 6th Ave N. (Jason & Megan Gehrman) Parcel ID: 3111823120022 City: Orono State: MN _ zipcode:_55356, _.— optional section: Sewage Tank Compliance Certification This form does not represent a complOts 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 SETS 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: Comp fi nce inspection form Existinu system (wq-wwists4-3lbb. This form can be found on the MPCA website at ,.http :/Avww.pca.state-mn.uslvvaterlasts-and-mats-technical-and-cornalrance-criteria. 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 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. Ig Certificate of sewage tank compliance Affirm all three statements: The SSTS does not contain a seepage pit, cesspool, drywetl, 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. Company information Company name: Alb in's Se tic -Pumping, LLC Business license number: 3346 ❑ 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. Designated Certified Individual (DCi) Information Print name: Peter Peterson _— Certification number: 9227- - I personally conducted ft work described above as a Designated Ceditd individual of a Minnesota -licensed SSTS Maintenance Business. l personally conducted the necassary procedures to assess the compliance status of each sewage tank in this SSTS, Designated Certified 04/26/2023 Individual's signature: s Date (mm/dd/yyyy): www.pca.state.mn.us 651-236-63W 800-657-3864 Use your preferred relay service Available in alternative formats wq-wwists4.38 • 1127117 page 3 of 3