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Property Address: 2920 Fox Street <br />Business Name: Rusty Olson Soil & percolation Tesl <br />1. Impact on public health — Compliance component #1 of 5 <br />Compliance criteria: <br />System discharges sewage to the <br />ground surface <br />Date: 8/5/2024 <br />Attached supporting documentation: <br />❑ Yes- ®No ❑ Other: <br />® Not applicable <br />System discharges sewage to drain ❑ Yes- ®No <br />tile or surface waters. <br />System causes sewage backup into ❑ Yes' ® No <br />dwellina 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. Nothing was found <br />2. Tank integrity — Compliance component #2 of 5 <br />Compliance criteria: <br />System consists of a seepage pit, <br />cesspool, drywell, leaching pit, <br />or other pit? <br />Sewage tank(s) leak below their <br />designed operating depth? <br />❑ Yes' ® No <br />❑ Yes- ® No <br />If yes, which sewage tanks leaks: <br />Any "yes" answer above indicates the system <br />is faiiing to protect groundwater. <br />Describe verification methods and results: <br />Elmer J. Peterson Company pumped the tanks. <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 5/8/2024 <br />(mmlddlyyyy): (must be within three years) <br />(See form instructions to ensure assessment complies with <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.rnn.us <br />wq-wwists4-31b • 4/28/2021 <br />• 651-296-6300 800-657-3864 use your preferred relay service Available in alternative formats <br />Page 2 of 4 <br />