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Aug 29 08 04:21 p 763-213-0699 763-213+0695 p.3 <br /> � cx:, �� - �:�; <br /> Parc�l number: � � � Systern status: �Compliant ❑Noncompliant <br /> . (as detertnined by1'his iorm) <br /> Tank Integrity and Safety Compliance <br /> Compliance Issue #2 of 4 , <br /> Date of observation: � —'�-q -C,�1 Reason tor observation: <br /> This form expires on(three years): <br /> Compliance questionslcriteria: (Required) Verification Method�":(Optional) <br /> Check�he a ro riate box (Check the appropRate boxJ <br /> Does the system oonsist of a seepage pit", ❑Yes No �. Probed tank bottorn <br /> cess ol,d U or leachin it? <br /> Do any sewage iank(s)leak below their ❑Yes (�No ���rved Eow liquid level <br /> desi ned o ratin de th? ' ` �Examined construdion records <br /> If yes, ide�ify which sewage r' ❑ Examined empty(pumped)tank <br /> tank leaks. � :� � probed outside tank for"black sal" <br /> Any'�es"answ�er indrcates th the system is failJng to pro(�ect � ' ' <br /> ground water. ❑ Pressure/vacuum check <br /> � ❑ Other: <br /> ' Seepage pils meeting 70802550 may be compliant if allowed <br /> in ordinance by loca!permitting autho�iry. <br /> "No standaM protocd exJsfs. This liat Is not exhaustive,� <br /> sequential orde��pr does it fndicate whlch Combinstions <br /> are necessary to make this determinatio�, <br /> Safety Check <br /> 1. Are any maintenance hole co�rers damaged,cracked,or appeared to be sbvcturaly unsound? ❑Yes" �No <br /> 2. Were al!maintenance hole covers replaced in a secured manner(e_g.,all screws replaoed)? �Yes ❑No` <br /> 3. Was secondary access restraint present(safety pan,second cover,or safety neiting)-highly recommended. ❑Yes �No <br /> 4. Was any olher safety/heaRh issue present7 ❑Yes' �No <br /> Explain: <br /> 'System is an imminsnt threat to publlc/walth arrd safety. <br /> Certificatiort <br /> This form is to be completed and attached to 1he Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compliance <br /> Inspectlon Form for Existing SubsurFace Sewage T�eatment Sysbms.Observations, inlerpretaiions,and canclusions must be <br /> completed by an inspector,maintainer,or service provider.Completed form musi be submitted to the local unit of govemment within <br /> 15 days. <br /> � <br /> Property owner name(s): /o2C9-C� //����?�,� <br /> Property address: �,'��.7 � �. J7�:� C9�`�u�-y�.r,� <br /> Properly owner's address(f different): <br /> County: � . Phone• � l�. " �� � �' I C ` <br /> I hereby certi/y that I persona►ly made the observations, inierpretations, and conclusrons reported on this fomr and that they are <br /> correcf. <br /> Name: Certificaiion number: J�' �JI � <br /> , T�'_i <br /> Business lic �se name and number: _.���7, �- ��.�(y���� �yL.t� . or <br /> Name of local unit of govemment: <br /> Signalure: .� � ---------------- �ate: �-�- ��T--C��_ _ <br /> _ ` . _ <br /> wq-wwists4- 1 Complionce lnspeccion Form jo�Existing SSTS <br /> 4/fl08 <br />