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<j/12/2610 08:16 952-955-5071 BURNS EXCAVATING PAGE 04 <br /> Parcel number. ' Sysbc�rl si�ua '�I Compliant ❑Noncomplfent <br /> ' ; (as dQti�kr�li�ed'by thia form) <br /> Tank Integrlty and Safety Co�npliance— Compliance Inspection Form fior Existing SSTS <br /> Compliance Issue #2 of 4 � <br /> Date of observation: 10-11-10 Reason far observaation: Transfer of tide <br /> This form expires on(three yesrs): 10-11-13 <br /> Canpliance que�tlons/criterla: (Requirec� Verlflcation Method": (O�tionaq <br /> Chedr Me a bnx _.. (Chedc the ePP�P►iaGe box) <br /> Does the system consist of a seap�ge pir, ❑Yes �No � prvbed tank baitom <br /> oesspovl,drnNell,a�leachin ' . <br /> Do arry sewage tank(s le2 belaw�elr ❑Yes �No � Observed low liquid level <br /> d ' ned o tin de � Examined cor�struction records <br /> If y�,iderltify wh�h��•�� � Examined empq►(pumpedy tank <br /> sewage tank le�ks- ' I [� Probed outside tank for'bladc soil" <br /> Any"yus"answ�ar IndlcaZas�ha!ihe ays[oen!s faNing tq protec! <br /> �d�� ❑,Rr+essur�Jvecuum chedc <br /> p other: tanks w�ere vumped <br /> ' S�page Pits meeHng 7080.2550 may be compliant if alla�w�ed , <br /> in ordinenoe by local permitting authorily. <br /> '"Mo stende►d protoco►exists. This Ust Is nct exhausdve,r'n <br /> sequentle!or�fer,nor does��indicate whfch combinaMo�s <br /> ere nee�sssry to meke this determinetion. <br /> Sefety theck <br /> 1. Are mairY6enanoe hole covers damaged,cradced,or appeared to be s�uetuially unsound7 ❑Yes" �No <br /> 2. Wae m�nt�nanoe hole covers replaoed in a secured marmer(e.g.,screws replacad)7 �Yes Q No* <br /> 3. Was seeondary acoe�s restrsiM present(sefelY Pa�,second caveK'.or safeb nettln9)—highly r�commended. ❑Yes �No <br /> 4. Ate o�tl�er ssfelyfiesllh issue pr�sent? ' ❑Yes" �No <br /> �Rr --- ' <br /> �ystem la an imml�erit��t to pu[�lic heelth end salety. ' <br /> �, . <br /> Certiflcatlon � <br /> This fortn is to be completed and attac�hed to the Summary Form of the Min�esota Polludon Condnl Agencys(MPC�Compliance <br /> Inspectlon Fomi for F.�Isting SubsutFAce Sewage Trestrnent Systen�s.ObseNations,iM�rpret�tions,and Conclusiorls must be <br /> oompleted by an inspecto�,mair�tainer,or senrioe provider.Completed foRn must be submitted to�e locel unk of govemment wRhin <br /> 15 days. <br /> Property owner neme(s): <br /> Properly address� 700 Bth Stre�t Ave.North, Orono,MN 55391 <br /> Property ovmer's address(K dNterent): � .,..� <br /> Caunty: Henn�in Properly owner phone: _____ <br /> 1 hereby ceitlfy thet I persortarfy made the obs+ervations,ir7terpretafiorra, end conc/usions reporled on this fiorm and d�at dhey ere <br /> correc.t . . <br /> Nam�: Pe_mel Hen�es CeAification number: 2064 ___ <br /> Business licen�na d number: Chip's Septic Senrice LLC ; or <br /> Name of local unit cf mma y„r ' _ <br /> ��.. <br /> , .�c..._ `Dste: 10•11-10 <br /> 8�gnatun• <br /> www.pca.state.mn.us • 651•296-6300 • 800-657•3a64 • TTY 651-Z8Z-5332 or 800-657-3964 • Av�Uable in alternative formdts <br />