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. � , <br /> Parcei number: � System status: tB'Compliant ❑Noncompliant <br /> (as determined by this form) . <br /> Duane s Septic Service, LLC <br /> 10502-31st Place N.E. <br /> Tan3c Integrity and Safety Compliance � St. Michael, MN 55376 - <br /> Comptiance lssue#2 of�4 7s3-497-27s4 <br /> Date of observation: � - 3 (i - 1 a Reason for observation: <br /> This form expires on(three years):� '7 - 3 G - f `� <br /> Compliance qusstions/criteria: (Required) Verification Method"*:(Optionap <br /> Check the e ro riafe box � (Check the appropriate box) <br /> Does the system consist of a seepage pit', ❑Yes No [�'�robed tank bottorri . <br /> cess ool,d ell,orleachin it? � - <br /> [�Dbsecved low liquid level <br /> Do any sewage tank(s)leak below their. �Yes �j No ._,/ - � . <br /> desi ned a eratin de th? CI Examined construction records � � <br /> !f yes,identify which sewage , �Examined ernpty(pumped}tank <br /> tank leaks. � � , �robed outside tank for"black soil" ' <br /> Any"yes"answer Indfcates that fhe system!s fa!ling to protect . <br /> ground water.� ❑ Pressure/vacuum check <br /> ' ❑ Other. �. ^.��.0 6� <br /> ' Seepage pits meefing 7080.2550 may be compliant if allowed - <br /> in ordinance by local permitting authority. , <br /> '*No standard protocoi exiSfs. This list is not exhaus(ive,in � . <br /> . sequenGal order,nor does it indicate which combinations ' <br /> ars necessary to inake this deferminafion. <br /> Safety Check . - . . - <br /> 1. Are any maintenance hole covers damaged,•cracked,or appeared to be structurally unsound? �Yes' �.�#6�` . <br /> 2. Were all mai�tenance hole covers replaced in a secured manner(e:g.;all screws replaced)? . es ❑No` <br /> 3. Was secondary access restraint present(safety pan,second cover,or safety netting)-highiy recommended. � Yes = o <br /> 4: Was any other safety/health issue present? : ❑Yes* �� � <br /> � Explain: <br /> *System Is an lmminent threat to public healtit and safety. <br /> Certification - <br /> This foRn is to be compieted and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA}-Compliance <br /> lnspection Form for Existing SubsurFace Sewage Treatment 3ystems.Observations,interpretations,and conclusions musf be <br /> completed.by an inspector;maintainer,or service provider.Completed fonn must be submitted to the local unit.of govemment within <br /> 15 days. . � <br /> Property owner name(s}: �� � � � � � ; � �� � Z r � ~ <br /> Property address: �j I "� �n. 'l�� �o �i►��° ,'1 (�-,—�,� J S _�S� <br /> Property owners address(if different): <br /> County: � � i] j)C v.!!� Phone: <br /> I hereby certify that I personally made the obsenrations, interprefa6ons, and conclusions reported on fhis form and fhat they are <br /> comecr. <br /> Name: _J l,l Q �'l� ��G��►`7�_I Certification number. C � L �� `/ <br /> Business license name and numbe� I�(,��1,0 �� ��.�,t� �'I C 1-F'{'V JC e�- �C �-s Lf or <br /> Name of local unit of�ovemment: � � <br /> Signature: � Date: f- 3 L, � l�� � <br /> wq-wwists4-31 Complfance/nspection Form for Existtng SSTS <br /> AI1/08 . ' <br />