Laserfiche WebLink
11f05/2010 66:47 7634975611 SPTESTINGINC PAGE 67/69 <br /> Nov U'I 1012;58p Elmer J,Peld�son Co, 763-972-7217 p.:� <br /> P9rcel number. 9ysl�em steh�s: �Campllant ❑Nor►compliant <br /> • • (ae detemfrned bY this fonn) <br /> Tank IAtegrity a�nd Ssfetyr Complia�nce- Corrrp�ance Jnspe�tion Fom�for Existing SSTS <br /> Compliance Issue #2 of 4 <br /> Oate aF observation: 11l1/40 Resson for obsetvatlan: P����e <br /> 7�is form expires on(three y�ars�: 11fi110 <br /> Cornp{ianco questlonslcMena:(Requiredy VerlRcation(Wethod":(Optlonal) <br /> � heck fhe a ro 'Ate bex (Chedt!he approiwiete bv�) <br /> Gves the system co�sist vf�seepage piC, Q Yes �No n Pro6ed tank bolkom <br /> Cess ool d ell or leachi �t? <br /> [I Observed low liquid level <br /> 17o any sEwege tar+k{s)le�k belvw their ❑Ye� �No <br /> d� ned e ratln d ? (] Ex9mined cor�truction�ecords <br /> IFyes,identity which � Exami�ed empty(pumped�tank <br /> sewage Ix+nk leaks. [] Probed oWside tankfar"blacK soli" <br /> AAy��ye5'8/13W9�1/1d�f�tE�S lh�8t�!Q 9]f�efll(S�flfFlg td p/nl9CZ <br /> gmUHtl 1Ys1er. ❑ PiessureMacwm chack <br /> ❑ OthE� - - �...., <br /> ' Scepege pils meeling i0d0.2S50 may be compllant iF allowed <br /> in ordinance by lasal permittiilg fl�ihorlly. <br /> ••No sler�dar+d�rvbeof exr�s.71sis list is eo�erha�stiv@,In <br /> scquanNo/order.nor doas it mclJcate wMch con►Wnallons <br /> �necosaary fo make fhis detarminstio+�. <br /> Safety CheCk <br /> 1. l�re main��anoe holo covers dam9ged,cracked,or appe�d to be strudi�rally unsound7 ❑Yes" �J No <br /> 2, Were malnt�nance htole covers repl�ed In e s�eured manner(e.g.,screws replac�? �Yes Nd <br /> 3, W�secorldary a�ess res4'f11nt pr�eM(seteq►pa�.secand cover,or safety netU ng)-hlghiy recommended. ❑Yes� �f No <br /> d. Are ott�er safe2yltiealth lssue preserit? ❑Y�' �No <br /> Exphain: ___ �, <br /> "system is an Imom��rent tltre�t ra puarlc he�rh anasalaty. <br /> Certif�catien <br /> This form is to be completed and att�ched to lhe Summary Form of the MinnPsvla Polluti�Cootrol�qencY's(MPCA)Compllance <br /> Inspectlon�orm fo�Exlstlng Subsurl�ae Sewage TreattnenCSystems.Observa�ons,InUerpretaqons,and cuncluglan�nxist bo <br /> completed hy an inspector, ms�inialnor,or service provider,Completed Form muat be sullmitbed#o thc local unit of govemme�twHhin <br /> 15 days. • <br /> Property own�r name�s): <br /> Prope�ty address: 4B5 N.stu6bs Bay Rosd Long LakE,MN 55356 <br /> Properly owner's address(�td�fteren!): .._._.._.._..._.. <br /> County: Mennepin_ Properly oWner phane: <br /> I he�eby certly thal l persontr/�y made('he observations,rnterpretations.and oonclusions r+eported on this form end fhat lfrey ere <br /> carr�d. <br /> Name; James Breegelmenn � Cer6ificativn numbar. <br /> Business licen�e name and number: Elmer J.Petei!aon Cn. fJoense�219 4r <br /> Name of laea �mment <br /> SignatuP'e: pa�; 11l1/10 <br /> www.pca. � .rnn.�,s • 66�-z9e-6300 • eao-657-3664 • TTY 651-Z62-533Z or a06657•38d4 � Avail�ble In alternativa fom�ats <br /> wq�wwlsts4-31 • s13AI04 Poge 3 of 8 <br />