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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 ❑ Yes ® No <br />dwelling 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 />visual <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, FEI es' ® No <br />cesspool, drywell, leaching pit, <br />or other pit? <br />Sewage tank(s) leak below their ❑ Yes ® No <br />designed operating depth? <br />i <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 />Tanks were pumped out at the time of inspection. <br />Attached supporting documentation: <br />® Pumped at time of inspection <br />Sewer Services <br />Name of maintenance business: Inc. <br />License number of maintenance business: 2502 <br />Date of maintenance: 7/27/2023 <br />❑ Existing tank integrity assessment (Attach) <br />Date of maintenance <br />(mm/dd/yyyy): (must be within three years) <br />(See form instructions to ensure assessment complies with <br />Minn. R. 7082.0700 subp. 4 8 (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 • 1/11/21 Page 2 of 4 <br />