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. . � �, , , ; <br /> Parcel number. � � System shatus: �ompliant ❑Noncompliant <br /> (as detemrin � <br /> - � ��s.� <br /> 1�.$1:���1. ' <br /> .5:�,='A�#�dael, �.11���.�. .6 : <br /> Tank Integrity and �afaty Compliance � � <br /> _ Compiiance Issue#2 of 4 � � <br /> O- !�� �e ����-a �� <br /> Date of observation: � 'O ' Reason for observation: - <br /> � This form expires on(three years): �'—g� �� � � � . <br /> Compliance questions/criteria: (Required) � Verification Method"`:�(OptionaQ _ <br /> Check the a ro riate box � (Chedc he appropriate bdx) � <br /> Does the system consist of a�seepage pit', ❑Yes o ���nk bottorri . ` <br /> �cess ! d II or leachin it? - . , _ <br /> Qo any sewage�tank(s)leak below their. �Yes No � Q Observed low liquid level . <br /> desi ned o ratin de th? � � -Exa ined construction records . � . <br /> if yes,identify which sewage - _ . Examined emPty(Pumped)tank - <br /> tank leaks. , � � � <br /> � , � Probed outskfe tank for"black soil' <br /> Any"yes"`arrswer indlcates that the system/s failing to protect - : . <br /> ground water.� . . ❑ Pressure/vacuum�chedc � . . <br /> . _ � - . � ❑ Other: � � <br /> ' Seepage pits mee�ng 70802550 may be compiiant lf allowed � . <br /> in 9rdinance by.local permitting'authority. . - - <br /> - � • "No standanl protoco!exists. This list is not exhausfive,in� ` : <br /> � sequential o►der,rror does it indlcste which i�mbinations . ' <br /> . � . ais ner.sssary to•inake-this determination. . � <br /> : _Safety CMeck - - . : � � : <br /> 1. Are any maintenance hole covers damagod,�cracked,or appear�ed to be structuraily unsound? 0 Yes' � _Nb� ` � . <br /> �2. Were all�maintenance hole covers replaced in a secured manner(e:g.;all sc.�ews repiaced)? �_. . Yes ❑No*. <br /> 3. � Was secondary access restraint present Fsafety pan;second cover,or safety netting)—highly�ecommended. ❑Yes Ll ryo <br /> 4: Was amr other aafety/health issue preaent? . : - . . - ❑Yes* L�'IVo <br /> . Exp{ain: � . - — . <br /> *System is an Imminont�reat to publlc healdi and ssfety. . � <br /> Certification � . � <br /> This fonn is to be completed and attached to the Summary Form of.the Minnesota Poliufion Control Agency's(MPCR)-Compiiance <br /> Inspaction Form for Existing Subsurface SewageTreatrnent Systems.Observationsr�interpr±etatwns.and conclusions must be_�. � <br /> completed.by an inspector,maintainer,or servic�provi8er.Completed fortn mus!be submitted to the local unR�of govemmQnt within <br /> 15 days. � � <br /> � . • � , - � . . <br /> Property owner name(s): l�/1 Gr�« i �� �dy . . <br /> Property address: '`�O Sd �� • Rd lP . -� <br /> Property owner's address(if different): _ <br /> � County: Phone: � . <br /> 1 heieby certily that l personally made the observations, interpretstiona, and conclusions reported on this foRn and that they are <br /> comecr. - � � � <br /> Name: � i r1, � �h Y Certification number. �-a� �7- . . � � <br /> ' Business license name and number. � h rj��1.L ,�Pr'ViCP: ��� - ��_�" or . � <br /> Name af txal un' ovemment: � : <br /> Signature: . . Date: �g" � � <br /> wq-wwlsts4•31 . _ � Compliance Inspectfon Form for Existing SSTS <br /> e��inR - <br />