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04/15/2010 11:58 7634988290 ' RUSTYS PERC TESTING PAGE 04 <br /> --� . � <br /> Paros�rnimber: 31�te23�2000'I ' sy�staa�: �I compl�+t CI Nonoompuane <br /> (ea diell�emwrwd dY thia Go�ml <br /> Tsnk In�s�rit�l�nd �ahtY C�P��� : <br /> Compliance Issue #2 of 4 , ' � . <br /> Dete aF ob�va�on: �JOB/10 Rmeso�,for obeerve�ion. , i Tra�sier <br /> This fam eoq�ires on(Un'e�years): � <br /> Cqnplf�noa qu�stb�lcrib�ris:(Requined) ' Vsriflcatlon M�thod":(�P�one� <br /> cl�a�C�he daar ' (G1nsc#u�e a�oprie�buxJ <br /> poes the syatem oonsiet af e seepsge Pit". D Yes �No �j probed t�k botbm <br /> a � Obseaved low Gquid level <br /> po�ry aew�e 1,ar�k(sI leak below tl�eir ❑Yes ($1 No , � Examinee oor�slnrc�lon reoads <br /> ? <br /> �Y������ ❑ Examined emph►(P�tenk <br /> tank Isaks. , ❑ Probed ouleide�nk for"bladc saT <br /> /ury rjws'�nswer Mdcabs tlat HM s�b�n Is�a►probct 0 ,P�+essure/vecuum check <br /> ��� <br /> ❑ Ott�' , PaRerson CampanY <br /> ' geePssp Pi�s meedn9 7080.?.b50 maI►De oompse�rt if albwed <br /> in oNinanos by local PemdGfnB eutho�h►• � ,. : ;.'; <br /> �"11b s�r�s+d Prntc+aol exist� ThlB Atat is not ezNauatMs�M <br /> �q�or�isr,r�or duea�w�dicate Nddch�ornNlneti�ons <br /> . � � .�eqe necessery b n�ke EINs detenn�nafbn• <br /> Safe�ty Check � <br /> 1. Ais any mainlenenos hob oo+rers dam�ad,asdcsd,a adPearod�o be sb�u�nNY unsqund? ❑Ye�• �No <br /> Z. W�s sp m�nbei�nnos hols c�s re�xd M a�sa+red menner(ap..all sawrs pepldoed� �Yea ❑No' <br /> 3. Was seoa�darY aooess iesbsint W+e�ent(saTsty Psn.,seoond co�ro�,vr salelY netl1�0)—hghh reoo�ra�s^ded. ❑Yas �Nc <br /> 4. Wss arry atl�er�afst�►R�ealth iawe Pro�ent? r r , , ❑Yas' �No <br /> ��� ' <br /> �ya0wri l�sn�mrn�nt tl�nd in pyblk I�IMh and saFety , <br /> ;4 .� <br /> ,. <br /> Certffication . ' <br /> �rnls fonn is to be compat�e ana�ed�o the summen►F«m af ine nANn�aote�Pdl�n�coi,tia Agenc�rs(MPCA)canplisnc. <br /> Inapectlon Form fvr Exisqng Subsuf�cs S�wap�T�bnent�-Observedona�k�rp�ons,end oor�uaior�s must be <br /> oompl�d b'!►an 1nsPecbot��r�tak�,or se�viCe profvkbr.(:ompl9ted f4nn h�q,be�uhh��r�iM,�d to ths iocal urdt o�govemme�wilhir� <br /> 15 days. ! ' ; � ' '. . <br /> Property vwner neo�e(s): AIGd�ael 8 Rebecca Neleo�+ ' '{` . <br /> Propeiiy address: 4260 Sidh Av�s N. Oraa MN 559�0 . ,,,�;. <br /> Property vwra�s addr�ess(�d�: <br /> CouMy: Herx�in � P��� . <br /> •� <br /> �ns►eap oera9ry►fhat�per�ov�lY,nede fhe obsen►ai�ov�s.rMe�eta�or�s.e�►rd,Gondumians�apoRed on a►is ro►m end met aisy a►e <br /> co►r�cx ,� , � , <br /> Narrie: JaceDh J Olson _ Ce�iifi�tion number. 1256 <br /> Buanea�qcense neme snd m�ribe�: Rue�i�r Olson's aoM e�d ' �esWig Uc�810 a <br /> Nama of locet�m�. C" of Or�o��o '! , <br /> ��: �' pa�e:, 4/'I?J10 <br /> ' <br /> wp-wN�lsts431 Carngllrinte Inspe�cNoA Fortn for E�dst'!ng 5573 <br /> �/I/A6 j' � , ; '�, ' ��' �� ,r" <br /> . <br /> � , <br /> � ' <br />