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Property Address;]::' <br />Business Name: Date:Jf <br />I. 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 />the or surface waters. <br />System causes sewage backup into ❑ Yes* ® No <br />dwellinq or establishment. <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 />Attached supporting documentation: <br />❑ Other: <br />❑ Not applicable <br />2. Tank integrity — Compliance component #2 of 5 <br />Compliance criteria: <br />System consists of a seepage pit, ❑ Yesw ❑ No <br />cesspool, drywell, leaching pit, <br />or other it? <br />Sewage tank(s) leak below their ❑ Yes* ❑ No <br />designed operating depth? <br />If which sewage tanks leaks: f <br />Any "yes" answer above indicates the system <br />is failing to protect groundwater. <br />Describe verification methods and results: <br />16ciJF; <br />Attached supporting documentation: <br />❑ Empty tank(s) viewed by inspector <br />Name of maintenance business: <br />License number of maintenance business: <br />Date of maintenance: <br />❑ Existing tank integrity assessment (Attach) <br />Date of maintenance <br />(mmtddlyyyy): (must be within three years) <br />(See form instructions to ensure assessment complies with <br />Minn. R. 7082.0700 subp. 4 6 (1)) <br />❑ Tank is Noncompliant (pumping not necessary- explain below) <br />❑ Other: <br />https://www.pca.state,mn,us 651-296-6300 800-657-3854 - Use your preferred relay service Available in alternative formats <br />wq-wwists4-31b • 4/28/2021 <br />