05-22-2023 Septic Compliance - Laserfiche WebLink

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Patrick & Monica Steiner Property eddreas: 4461 Bayside Rd Parcel it)_ 0611,723210007 city: Orono _ state: MN _ zip code:_ 55359` Optional section: Sewage Tank Compliance Certification This form does not represent a complete system inspection report and only certifies sewage tank compliance status. Instruedons: This secdion of the form may be oompleted and signed by a Designated Certified Individual (DCI) of a licensed SSTS 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. Compliance inspection form - Existing;ystem (wm-wwistj! �:3 2i. This form can be found on the MPCA rmbsite at httos-llwww oca state m uslwaterNsts-and-mets-technical-and-comptlance-criteria. The information and certified statement on this form is required when existing septic tank compliance status is determined by an Indhddual 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 (i3) 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 kxcal 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. ® Certificate of sevrags tank compliance Affirm all three statements: The SSTS does not contain a seepage pit, cesspooi, drywall, teaching pit, or other pit. it does not contain a sewage tank that was designed to be watertight, but subsequently teaks below the designed operating depth. ® It dices not represent an imminent safety threat by reason of unsecured, damaged, or weak maintenance Dole cover(s) or other unsafe oondition. Company Informaticon Company name: Albin's Septic Pumping, LLC Business license number: 3348 ❑ Notice of sewage tank non-compllance Select all that apply: ❑ The SSTS has a seepage pit, cesspool, drywall, 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 weals maintenance hole cover(s) or other unsafe oondition. Designated Certified Individual (DCI) Information Print name: Peter Peterson Certification number: 9227 ! person* conducted rite work desraibed above as a Designated Cedded inditridual of a Minnesote4censed SSTS Maintenw= Business. I personally conducted the ry procedures to assess the compflance status of each sewage tank in this SSTS: Designated Certified Individual's signature: ! Date (mmlddryyyy): _ 06/24/2021 www.pca.state.mn.us 651-296-6300 • 800-657.3864 Use your preferred relay service Available in attemattve formats wq•ww1sts4.38 • 912711;r Page 3 of 3