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Parcel numt�er: � System status; Compliant ❑ Noncompliant <br /> (as determined by his form) <br /> Tank Ititegrity and Safety Cotnpllance <br /> Compliance Issue #2 of 4 <br /> Date of obsarvation: Reason for observation: �i � __.__,..�._____— <br /> This form expires on(three years): _ _ <br /> Compliance questianslcriteria: (Required) Yerification Method"'`: (Opdonal) <br /> Check the a ro riate box (Check the eppropriate box) <br /> Qoes the system consist of a seepage pit•, ❑Yes o � Probed tank bottom <br /> cess ool,d ell,or leachin it? <br /> ❑ Observed low fiquid level <br /> Do any sewage tank(s)leak below their ❑Yes No <br /> desi ned o ratin de h? �Examined consvuction records <br /> If yes, idenMy which sewage �Examined empty(pumped)tank �l�-7�f� <br /> tank leaks. ❑ Probed outside tank for"black soil" <br /> Any•�es��aeswerindlcates thar the syst�em is fall/ng to protect <br /> ground water. • ❑ Pressure/vacuum check <br /> ❑ Other: _ <br /> ' Seepage pits meeting 7080.2550 may be compllant if allowed <br /> in ordinance by local pertnitting authority. — -- � <br /> •',No standarsd protoc�o►exists. This lisf is not exhaustive,in <br /> sequentia/order,nor does ft indlcate which combinarions <br /> are necessary to make fhis determfnation. <br /> Safety Check <br /> 1, Are any maintenance hole cevers damaged,cracked,n�appeared to be st�ucturally unsound7 ❑Yes' �No <br /> 2. Were alt maintenance hole covers replaced in a secured manner(e.g.,all screws replaced)? �Yes ❑No' <br /> 3. Was secondary actess r�traint presenl(safety�an,second cover,or safety netting)—highly recomrnended. ❑Yes No <br /> 4. Was any other safetylhealth issus present9 ❑ Yes" No <br /> Euplain: _�_ � _ .--- --._.. <br /> 'System Ts an Immin�ent threat�o publlc health and saiety_ <br /> Certificatiun <br /> This form is to be amplet�d and aitached ta the Summary Fo�m of the Minnesota Pollu�on Control Age�cy's(MPCA) Compliance <br /> Inspectlon Fortn for Exis�ing Subsurfsee Sew�ge Treatment Systems.Observations, interpretations,and conclusions must be <br /> completed by an inspectorj maintainsr,or se�viCe pl'ovider. Completed Mrm must be submitted lo che loca� unit of government within <br /> 15 days. <br /> Property owner name(s): � I ._—. __ ..., _.—_.__ <br /> Property address: —12`�� �' 1� .., . <br /> Property nwner's address 1if di[fsrent): ., ,--. <br /> County: ��\� Phone: �.., . ... <br /> 1 hareby cerllfy thai 1 personally made the obseru8tions, inferpretations.and cenc/usians roported on this form and fhat they are <br /> correci. <br /> Name: _.,,,,J�1 ��U� �� CerUfication number; 1�0�1 __._. .. _ <br /> Business license name and number: � tior��U�YJ �C4_.� ��.��� .. _ °� <br /> Name of local unit ove nt: .. <br /> Signature: Date: ��.� <br /> wq•wwfs[54-31 Compliance Inspection Farm for Ezistfng SSTS <br /> 411I08 <br /> 50!£0 39dd ZttEEL8Z96 6Z�bt ZZ8Z/90I90 <br />