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Property Address: 4740 North Arm Drive West <br />Business Name: Rusty Olson Soil & percolation Testing Date: 5/4/2023 <br />1. Impact on public health -- Compliance component #1 of 5 <br />Compliance criteria: <br />System discharges sewage to the ❑ Yes* ® No <br />ground surface <br />System discharges sewage to drain ❑ Yes* ® No <br />tile or surface waters. <br />System causes sewage backup into I ❑ Yes- ® No <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 />Visual. Nothing was found <br />Attached supporting documentation: <br />❑ Other: <br />® Not applicable <br />2. Tank integrity — Compliance component #2 of 5 <br />Compliance criteria: Attached supporting documentation: <br />System consists of a seepage pit, ❑ Yes' ® No ❑ Empty tank(s) viewed by inspector <br />cesspool, dryweil, leaching pit, <br />or other it? Name of maintenance business: <br />Sewage tank(s) leak below their ❑ Yes` ® No License number of maintenance business: <br />designed operating depth? <br />If yes, which sewage tank(s) leaks: <br />Any "yes" answer above indicates the system <br />is failing to protect groundwater. <br />Describe verification methods and results: <br />Elmer J. Peterson Company pumped the tanks. <br />Date of maintenance: <br />® Existing tank integrity assessment (Attach) <br />Date of maintenance 5/1/2023 <br />(mmldd/yyyy): (must be within three years) <br />(See form instructions to ensure assessment complies with <br />Minn. R. 7082.0700 subp. 4 B (1)) <br />❑ Tank is Noncompliant (pumping not necessary - explain below) <br />❑ Other: <br />https://www.pca.state,mn,us 651-296-6300 800-657-3864 Use your preferred relay service Available in alternative formats <br />wq-wwists4-31b • 4/28/1021 Page 2 of 4 <br />