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Orono PID# 2711823320009 <br />David & Michelle Denniston Medina PID# 2711823230002 <br />Property address; 1200 Phillips Drive Parcel ID: _- <br />city: Orono - Medina __. State:_ -MN _ zip code:_ 55356_ <br />Optional section: Sewage Tank Compliance Certification <br />This form does not represent a complete system inspection report and only certifies sewage tank compliance status. <br />Instructions: This section of the form may be completed and signed by a Designated Certified Individual (DCI) of a licensed SETS <br />Maintenance Business who personally conducts the necessary procedures to assess the compliance status of each sewage tank in <br />the system. <br />When this section of the form is signed by a qualified certified professional, it becomes necessary supporting documentation to an <br />Existing System Compliance Inspection Report: Compliance inspection form Existing system LM-wwists!L-31 bt. This form can be <br />found on the MPCA website at https:ltww J.pca state mn ustwaterfssts-and,-msts-technical-and-compliance-criteria. <br />The information and certified statement on this form is required when existing septic tank compliance status is determined by an <br />individual other than the SSTS Inspector that submits the inspection report. It represents a third party assessment of SSTS <br />component compliance and is allowable under Minn. R. 7082.0700, subp. 4 Item (B) subitem (1). This form is valid for a period of <br />three years beyond the signature date on this form unless a new evaluation is requested by the owner or owner's agent or is <br />required according to local regulations. Additional Administrative Rule references for this activity can be found at Minn. <br />R. 7082.0700, subp. 4 Items B, C, and D; 7083.0730 Item C. <br />® Certificate of sewage tank compliance <br />Affirm all three statements: <br />The SSTS does not contain a seepage pit, cesspool, <br />dryweil, leaching pit, or other pit. <br />$( it does riot contain a sewage tank that was designed <br />to be watertight, but subsequently leaks below the <br />designed operating depth. <br />® <br />11 does not represent an imminent safety threat by <br />reason of unsecured, damaged, or weak <br />maintenance hole cover(s) or other unsafe condition. <br />Company information <br />Company name: Albin's Septic Pumping, LLC <br />Business license number: 3346 <br />❑ Notice of sewage tank non-compliance <br />Select all that apply: <br />[ The SSTS has a seepage pit, cesspool, drywell, <br />leaching pit, or other pit, <br />[] It has a sewage tank that was designed to be <br />watertight, but subsequently leaks below the designed <br />operating depth. <br />{] It presents a threat to public safety by reason of <br />unsecured, damaged, or weak maintenance hole <br />cover(s) or other unsafe condition. <br />Designated Certified Individual (DCI) information <br />Print name: Peter Peterson _ <br />Certification number. 9227 <br />I personally conducted the work described above as a Designated Certified Individual of a Minnesota -licensed SSTS Maintenance <br />Business. l personalty conducted the n ry procedures to assess the compliance status of each sewage tank in this SSTS: <br />Designated Certified <br />Individual's signature: _ Date (mmlddlyyyy): _05/18/2023_. <br />www.pca.state.mn.us • 651-246-6300 800-657-3864 Use your preferred relay service Available in attemative formats <br />wq-ww1sts4.38 • 1127117 Page 3 of 3 <br />