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1. Impact on public health — Compliance component #1 of 5 <br />Compliance criteria:___ <br />Attached supporting <br />-- - -- pporting documentation: <br />System discharges sewage to the ! ❑ Yes ® No <br />ground surface ❑ Other: <br />Not a <br />pplicabie <br />System discharges sewage to drain i ❑ Yes' ® No <br />tile or surface waters. <br />System causes sewage backup into ? ❑ Yes' ® No <br />dwelling or establishment. <br /><4I){/ "11F'S° anSIN@'r c)I)cil/e )ndicaros tho S{/'.,,-te?ll] is all <br />in)1))inerii rhrerr( to (,>uhlic, ltc t}I'ih ri-lfet)/, - -- <br />Describe verification methods and results: <br />Searched for surface outlet or ground discharge <br />Checked for back-up <br />2. Tank integrity — Compliance component #2 of 5 <br />Compliance criteria: <br />_._..-...-.. Attached sup <br />porting documentation: <br />System consists of a seepage pit, [] Yes* ® No <br />cesspool, drywell, leaching pit, ;-_._..__..._._ _ Pumped at time of inspection <br />or other pit? <br />" Name of maintenance business: <br />Sewage tank(s) leak below their !C] Yes ® No Sewer Services <br />designed operating depth? License number of maintenance business: 2502 <br />I <br />._ifyes, which sewage tank(s)_leaks: <br />c)s <br />An `' arisvc/ Y 1 u ai_)ovt, rr�dlc rho <br />is fc)/ill1CJ t`'C) !�!'Ud<?Ci' C r'oonC{tfl/<?1''E <br />_-----........ <br />Describe verification methods and results: <br />Pumped & Inspected <br />Date of maintenance: 4/26/2022 <br />❑ Existing tank integrity assessment (Attach) <br />Date of maintenance <br />(mm/dd/yyyy): -___-_- <br />(must be within three years) <br />(See form instructions to ensure assessment complies with <br />Minn. R. 7082,0700 subp, 4 8 (1)) <br />❑ Tank is Noncompliant (pumping not necessary - explain below) <br />❑ Other: <br />https://www.pcastate.mn,us 651-296.6300 --- 800-657-3864 __.___ _--_-_ <br />3864 <br />wq-wwi5t54.31b • 1111121 <br />use your preferred relay service <br />Available in alternative formats <br />