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Ply address: <br />2425 Thoroughbred Lane (Colin & Julie Davie) _ <br />Parceei lD: <br />04117'23110018 <br />City: Orono <br />_ State:. M N <br />_ zip code: <br />55356 <br />Optional section: Sewage Tank Compliance Certification <br />This form does not represent a cornpleft system inspection report and only eerdf'lea sewage tank compliianc 811:211M. <br />s. <br />insinuations: This erection of the form may be completed and signed by a Designated Certified Individual (DCI) of a ii muW SSTS <br />Mahftm rmoe Business who personally conducts the necessary procedures to assess the compliance edatus of each sewage tank in <br />the system. <br />VVherr this section of the form is signed by a qualified certified professional, it becomes necessary supporthV documentafm to an <br />Existing System Compliance Inspection Report: QgWience i This form can be <br />found on the MPGA website at <br />The information and certified statement on this form is required when ekisfjng septic tank compliance status is determined by an <br />Individual other than the SSTS Inspector that submits the inspection report. It nrpresenfs a third party assessment of SETS <br />=7ponent compliance and is allmmUe under Minn. R. 7482.0700, subp. 4 stern (8) sulxtern (1). This fame is valid for a period of <br />three yews beyond the signature date on this form unless a new evaluation Is requested by the owner or oawWs agent or Is <br />required according to local regulations. Additional Administra dve Rule references for this activity can be found at Minn. <br />R. 7082.4700, subp. 4 items B, C, and D; 7083.0730 item C. <br />IN {s tiftsta of swage tank compiianc* <br />Affirm all three staterr%K ts: <br />$I The SETS does not contain a creepage pit, cesspool, <br />drywel, feesed hV pit, or other pit. <br />It does not contain a sewage tank that was designed <br />to be wa*t, but sube;squently kraks below the <br />designed operating deepth. <br />]$� It does not represent an imminent safety threat by <br />reason of unsecured, damaged, or weak <br />maintenance hole cover(s) or other unsafe condition. <br />Company infonnafion <br />Company narne: Albin's Septic Pum&g, LLC <br />E] 14otice of seiwgp tank non -c rnpillancte <br />Select all that appy. <br />0 The SSTS has a seepage pit, cesspool, drywall, <br />leaching pit, or other pit. <br />It has a sewage tank that was designed to be <br />watertight, but subsequently leaks below firs designed <br />operating depth. <br />❑ It presents a threat to public safety by reason of <br />unsecured, damaged, or weak mahtenarrce thole <br />cover(s) or other unsafe card`ition. <br />Designated Certified Indhridual (DCll Inforrrtatlon <br />Print name: Peter Peterson <br />Business license number: 3348 Ced!fK:aWn number. 9227 <br />I pwWaafly cWdrrctad the work described above as a Designated Cerfftd Individual of a Minnese tb4csnsed SSTS Mairderrsrrae <br />BuaV?ess, I persormYy carr fed the ry procedures to assess the car "poarrcee status of each saw age tank in this SETS: <br />Desufrs � : - Date (mnvdd►yyyy):05/29/2019 <br />www.pa.statemn.us . +651-296-53110 • M657-3854 U$e your preferred relay service Avalt#ble in atternat:ive formats <br />rvq-ww1stsf-38 • 1127117 fpr 3 of 3 <br />