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Property Address: 9 Q 0'1.q V� <br />Business Name: . Q .('¢ W I Cr <br />1. Impact on public health — Compliance component #1 of 5 <br />Comolianrp rrifnrin- <br />System discharges sewage to the ❑ Yes* No <br />ground surface <br />System discharges sewage to drain I] Yes- ® No <br />tile or Surface watarc <br />System causes sewage backup Into �❑ Yes* ® No <br />dwelling or estahlishmpnr <br />Any "yes" answer above indicates the system is an <br />imminent threat to pijhlfc health and safet . <br />Describe verification methods and results: <br />2. Tank integrity— Compliance component #2 of 5 <br />System consists of a seepage pit, <br />cesspool, drywell, leaching pit, <br />or other it? <br />Sewage lank(s) leak below their <br />designed operating depth? <br />If <br />0 Yes' ❑ No <br />❑ Yes' ❑ No <br />Any "yes" answer above indicates the system <br />is failing to protect groundwater. <br />Describe verification methods and results: <br />Date: <br />Attached supporting documentation: <br />❑ Other: <br />❑ Not applicable <br />Attached supporting documentation: <br />* Empty tank(s) viewed by Inspector <br />Name of maintenance business: too <br />r <br />License number of maintenance business:_1 a a <br />Date of maintenance; <br />❑ Existing tank Integrity assessment (Attach) <br />Date of maintenance <br />(mrrVdd/yyyy), (must be within three years) <br />(See farm 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.mn.us 65i-296-6300 8MG57-3864 v Use your preferred relayservice <br />wq-ww15ts4-3Ib • 417802 <br />022 AvaElahle in alternatve formats <br />Page 2 of 4 <br />