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1. Impact on public health — Compliance component #1 of 5 <br />Compliance criteria: Attached supporting documentation: <br />System discharges sewage to the 17 Yes E-] No —j Other. <br />ground SUI-faCe <br />Not applicable <br />System discharges sewage to drain l_-'] Yes L-, -j No <br />the or sur -face waters. <br />System causes sewage backup into Yes No <br />dwelling or establishment. <br />Describe verification methods and results: <br />Visual <br />2. Tank integrity — Compliance component #2 of 5 <br />Compliance criteria: <br />System consists of F seepage pit. El' Yes 71 No <br />cesspool. drywell. leaching pit, <br />or other pit? <br />Sewage tank(s) leak below their El Yes E] No <br />designed operating depth? <br />If yes. which sewage tank(s) leaks, <br />Attached supporting documentation: <br />7 Pumped at time of inspection <br />Sewer Services <br />Name of maintenance business: Inc- <br />License <br />ncLicense number of maintenance business: 2502 <br />Dale of maintenance. 05/23/2023 <br />Existing tank integrity assessment (Attach) <br />(Date of r-nainteria rice <br />IVIM-r/dd;yyyyi (must be within three years) <br />(See foi7,n Instroctions to ensure assessment complies with <br />Miert R, 7082.0700 subp, 4 B (1)) <br />1 ank is Noncompliant ;pumping not necessary -- explain below] <br />rL-1' Other <br />Describe verification methods and results: <br />Tanks were pumped out at the time of inspection Carne, a inspection on the first two tanks are showing dertenoration of the <br />concrete baffles and both tanks will need to be replaced in the future At this time it does not consider the tanks to be non- <br />complient PLIMP tanks every 3 years <br />'1'ttPS://v,,:,,,,-,.D('! stalu,mw,—, 651-296-6`103 ycl:! Dri,fawed rciay service <br />Avadab e 'r' WLCI native fo, mats <br />Po, 9 r, 2 of 4 <br />