2630 Fox Street - Septic Compliance (12)

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Property address: 2630 Fox Street Parcel ID: 0411723420027 City: Orono State: MN Zip code: 55391 Optional section: Sewage Tank Compliance Certification This form does not represent a complete system inspection report and only certifies sewage tank compliance status. Instructions: This section of the form may be completed and signed by a Designated Certified Individual (DCI) of a licensed SSTS Maintenance Business who personally conducts the necessary procedures to assess the compliance status of each sewage tank in the system. When this section of the form is signed by a qualified certified professional, it becomes necessary supporting documentation to an Existing System Compliance Inspection Report: Compliangg inN; action form xistMg sv , en w wwist - L1 b This form can be found on the MPCA website at htt s.liv,.1 Nw.Qca.state.mn uj/wgtc. -! ss ts-and-msts-technica,! and-comtsliance-criteria. The information and certified statement on this form is required when existing septic tank compliance status is determined by an individual other than the SSTS Inspector that submits the inspection report. It represents a third party assessment of SSTS component compliance and is allowable under Minn. R. 7082.0700, subp. 4 Item (B) subitem (1). This form 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 owner's 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 Items B, C, and D; 7083.0730 Item C. ® Certificate of sewage tank compliance Affirm all three statements: ® The SSTS does not contain a seepage pit, cesspool, drywell, leaching pit, or other pit. ® It does not contain a sewage tank that was designed to be watertight, but subsequently leaks below the designed operating depth. ® It does not represent an imminent safety threat by reason of unsecured, damaged, or weak maintenance hole cover(s) or other unsafe condition. Company information Company name: Chip's Septic Services Business license number: 2064 ❑ Notice of sewage tank non-compliance Select all that apply: ❑ The SSTS has a seepage pit, cesspool, drywell, leaching pit, or other pit — "Failure to Protect Groundwater." ❑ It has a sewage tank that was designed to be watertight, but subsequently leaks below the designed operating depth —"Failure to Protect Groundwater." ❑ It presents a threat to public safety by reason of unsecured, damaged, or weak maintenance hole cover(s) or other unsafe condition — "Imminent Threat to Public Health or Safety." Designated Certified Individual (DCI) information Print name: Pernel Hentges Certification number: 4761 1 personally conducted the work described above as a Designated Certified Individual of a Minnesota -licensed SS7S Maintenance Business. I personally conducted the necessary procedures to assess the compliance status of each sewage tank in this SSTS: Designated Certified Individual's signature: Date (mm/dd/yyyy): 1/13/2026 www.pca.stabe.mn.us • 651-296-6300 • 800-657-3864 Use your preferred relay service & Available in alternative formats wq-wwists4-33 • 10112118 Page 3 of 3