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Property address: 27703 Rainey Rd <br />city: _Orono <br />Parcel io:04-117-23-'L3- 14 <br />state: -M N zip code, 55384 <br />Optional section: Sewage Tank Compliance Certification <br />This form does not represent a complete system Inspecdon report and only cestHiee sewage tank compliance Mahn. <br />Instructions: This section of the form may be ooxnpleted and signed by a Designated Certified Individual (DCI) of a licensed SSTS <br />Maintenance Business who personally conducts the necowA Y procedures to assess the compliance status of each sewage tank in <br />the system. <br />When this section of the form Is signed by a qualified certified professional, it becomes necaessa►y sppioor ►ff dXWrWM"W to ars <br />Existing System Compliance Inspection Report: .'this farm can be <br />found on the MPCA website at - _ . <br />The Wwmation and certifrel statement on this form is required when e=dng septic tank compliance status is deterrrr ned by an <br />lndtvktual other then the SSTS Inspector that submits the ksspedion report. It represents a turd party assessment of SSTS <br />component compliance and is alkwabie under Minn. R. 7082.0704, subp. 4 Item (8) subitem (t). This form is valid for a period of <br />three yam beyond the signature date on this farm unkess a new evalusW is requested by the owner or owner's agent or Is <br />regained ac cording to tocol regulations. Additional Administrative Rule references for this activity can be found at Minn. <br />R. 7082.0700, subp. 4 Items B, C, and D; 7083.0730 Item C. <br />0 Cwtificate of sewage tank compliance ❑ Notice of siewap tank non-compliance <br />Affirm all three statements: SBleflt an that apply: <br />The SSTS does not contain a seepage pit, cesspool, <br />drywek leaching plt, or other pit. <br />$� it does not contain a sewage tank that was designed <br />to be watertight, but subsequently leaks below the <br />designed operating depth. <br />21 It does not represent an Imminent safety threat by <br />reason of unsecured, damaged. or weak <br />malintenance hole covers) or other unsafe condition. <br />Company information <br />Company name: A(isirr's Septic I'urr!pinp 9 LLC <br />Business license number: 3346 <br />❑ 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 the designed <br />opera" depth. <br />it presents a thrsat topublic safety by reason of <br />unsecured, damaged, or weak maintenance hale <br />cover(s) or other unsafe condition. <br />Designated Certified Individual (DCll Information <br />Print name: Peter Peterson_ s� <br />Certification number: 9227 <br />I pammally C&MWed the work dembed above as a Desrvmted t.eri*d Indusdual of a Vrrnnesct&*9nwd SSTS MiMiu m <br />s sirs. l peraonaify ca xkxw dee ry procedures LCs assess Me co rnpfence status of each sewage tank its this SSTS: <br />Designated Certified h/ <br />Individual's signature: Date (nrrvddvyM): 02/0312019 <br />www.pmsMe.=.us 631-29Fr6.1' M - OW -657-3864 - Use Your pre!'erred relay service Avaitahle in alternative formats <br />wq-wwfstx+33 - 1127117 Page 3 of 3 <br />