1840 Fox Street - Septic Compliance

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Robert & Angilea McNae Property address: _ 1840 Fox St _ Parcel l e: 0311723420008 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: compliance inspection form -Existing system (-wwists4-3I b). This form can be found on the MPCA website at hft2a:lhvww.12ce.state.mn.us/watertsst -and-msts-technical-a!3d-co pliance-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 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 Items B, C, and D; 7083,0730 Item C. M Certificate of sewage tank compliance Affirm all three statements: The SSTS does not contain a seepage pit, cesspool, drywell, leaching pit, or other pit. jSf it does not contain a sewage tank that was designed to be watertight, but subsequently leaks below the designed operating depth. X It does not represent an imminent safety threat by reason of unsecured, damaged, or weak maintenance hole cover(s) or other unsafe condition. Notice of sewage tank non-compliance Select ail that apply: The SSTS has a seepage pit, cesspool, drywellp leaching pit, or other pit. [] It has a sewage tank that was designed to be watertight, but subsequently leaks below the designed operating depth. d it presents a threat to public safety by reason of unsecured, damaged, or weak maintenance hole cover(s) or other unsafe condition. Company information Designated Certified Individual (DCI) information Company name: Aibin's Septic Pumping, LLC Print name: Peter Peterson Business license number: 3346Certification number. 9227 —_ I personally conducted the work described above as a Designated Certified Individual of a Minnesota -licensed SSTS Maintenance Business. I personally conducted the n ary procedures to assess the compliance status of each sewage tank in this SSTS: Designated Certified 09/11 /2023 Individual's signature: Date (mm/dd/yyyy): -- www.pca.state.mn.us • wq-wwJsts4.38 • 1127117 651-296-63W i800-657-3864 use your preferred relay service Available in alternative formats page 3 of 3