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Property Address: I a, (1.e <br />Business Name: . Q •� N �, i til C <br />1. Impact on public health — Compliance component #1 of 5 <br />Compliance criteria: <br />System discharges sewage to the �[:] Yes• p No <br />ground surface <br />System discharges sewage to drain IEl 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 />Date: <br />Attached supporting documentation: <br />❑ Other: <br />❑ Not applicable <br />2. Tank integrity — Compliance component #2 of 5 <br />liance criteria: <br />System consists of a seepage pit, ❑ Yes' ® No <br />cesspool, drywell, leaching pit, <br />or other pit? <br />Sewage tank(s) leak below their ❑ Yes" ® No <br />designed operating depth? <br />If which sewacie tanks teaks; <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: Sra.1j!—' <br />License number of maintenance business: _ ) cl 9--) _ <br />Date of maintenance: <br />❑ Existing tank integrity assessment (Attach) <br />[late of maintenance _ <br />(mmldd/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 />http5://www.pca.state.mn.us 651-296-6300 800-657-3864 Use your preferred relay service Available in alternative formats <br />wq-wwists4-31h • 412812021 <br />Page 2 of 4 <br />