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MiNNESOTA POLLUTION CONTROL AGENCY Sewage tank integrity assessment form 520 Lafayette Road North Subsurface Sewage St. Paul, MN 55155-4194 Treatment Systems (SOTS) Program Doc Type: Compliance and Enfomernent Purpose: This form may be used to certify the compliance status of the sewage tank components of the SSTS. This form is not a complete SM Inspection report only a tank Integrity, aassaamsnt, and may only certify sewage tank compliance status when entirely completed and signed by a qualified prvtsadonal. SSTS compliance Inspection report forma can be found at httos:/Maww.Dca. state.mn.us/waterAnsoacdons. km4ra:tlons: This forth may be completed, and signed, by a Designated Certified Individual (DCI) of a licensed SSTS Inspection, makdernence, insfelletion, or service provider business who personally conducts the necessary procedures to assess the compliance status of each sewage tank In the system Only a Hosirsed maintenance business is authorized to pump the tank for assessment. A copy of this hilomallm shouts be eubmNled to the system owner and be rnai nfalned bythe licensed SSTS business for a period of Ave (5) yams ftn the saeeeernent data. yiharn fhla form is signed by a qualified certlged professbnel, it becomes necessary supporting documentation to an 6dsting System Compliance Inspection Report: Compliance in agection form - Facistinc system (wc-wwists4-31 b). This form can be found on tins MPCA wabefta at htMs://www Dca.state.mn.ushwater/Insrections. The Information and owWW statement on this form is required when existing septic tank compliance statue is determined by an individual olhrr than to SETS Inspector that subNts an inspection report. This form represents a third party assessment of SSTS component compliance and fs allowable under Minn. R. 7082.0700, subp. 4(B)(1). This forth is valid for a period of three years beyond the signature date on this form unless a new evaluation is requested by the owner or owners agent or Is required according to local regulations. Additional Administrative Rule references for this activity can be found at Minn. R. 7082.0700, subp. 4(B),(C), and (D) and; Minn. R. 7088.0730(C). Owner information Ownerillepresentative _I Property address: _ Local Regulatory Authority: system status System statue on date (mm/ddlyyyy): 1J 2-tee ! u Lc{ Grdncats of sewage tank compliance ❑ Notice of sewage tank non-compliance Compliance criteria: The SSTS has a seepage pit, cesspool, dryereA, load" pit, or otter pit - •'allure to Protect � ❑ Yes' P(No Groundwati A The SETS has a sewage tank that leaks below the designed operating depth -"Failure to Protect ❑ Yes' ?�No Groundwater." The SSTS presents a threat to public esfety by reason of structurally unsound (damaged, cracked, or w�lc) maintenance hole oover(s) or tide or any other unsafe condition - Imminent Threat to ❑Yes ps No Public Nnraltin or safety." r Any yes" answer above indicates sewage tank non-compliance. Company information Designated Certified individual (DCI) Information Company name: Duane% Septic Service LLC Print name: lei cuel h � �r4,t e' Business }lease number. L4286 Ceriftafion number. lg (o3 1 personalty conducted the work described above as a Dealiyrated Certified Indhddual of a Mfnnesots4ca rsed SSTS kwectian, maintenance, dnstaoaborr, oraervke pmvlder Suainess. / personally conducted the necessary procedures to assess the compliance status of each sewage tank in this SSTS. By typbapMgnbug my name below, I certify the above statements to be true and correct to the best of my knowledge, and that dds kibrmadon can be used Ibr the purpose afPro�rea%slr4lks karm. Designated Certified Indlvkluars slgrsiure: Date (mmlddlyyyy): {TMa dowrnerrt hoe been efactradcally signed. www.peaslatemnus 651-I9G68ap BW57-a664 Use your preferred relay service Available inauemameroman wq'Mw6tW-W • 41101 Pope t oil