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Property Address: a c{y.,!� \,/ q-�,_�oyj*ty _ <br />Business Name; —S - Q '► ti.] `, I hl t— Date: I <br />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* M 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 />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, ❑ Yes' ❑ No <br />cesspool, drywell, leaching pit, <br />or other it? <br />Sewage tank(s) leak below their ❑ Yes' ❑ No <br />designed operating depth?. <br />!Lyes, which sewage tanks leaks: <br />Any "yes" answer above indicates the system <br />is failing to protect groundwater. <br />Describe verification methods and results: <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 />(mm/ddlyyyy); (must be within three years) <br />(See form instructions to ensure assessment complies wits, <br />Minn. R. 7082.0700 subp. 4 B (1)) <br />❑ Tank is Noncompliant (pumping not necessary — explain below) <br />❑ Other: <br />httpS://www.pca.state,mn.us 651-296-6300 500-657-3864 use your preferred relay service • Available in alternative formats <br />wg-wwists4-33b • 4/28/2D21 <br />