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