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�� 07/18/269� 1:58 7634975911 SPTESTINGINC PAGE 09/10 <br /> Parc.�l numD�r: � _ System status: I�Compliam ❑Noncomp�artt <br /> . (as�alerrnJned by this�am} • <br /> Tank Int+�g ty and Sefety.Compliance � . ' - � � <br /> Complian�e su�#2 0�4 .` � � <br /> Oale of obse�rat'i n: 0-3������ ���°n ior obse�tion: � G1�11 �,�y1C.G �vY�np r'r�4 <br /> This form exp�res (fhree yea�s): ' /0- J ^ Z 016 � � <br /> Complianc�qa 'orislcrit�ria: (Requ�red) Veri�c�tion�Vlethod"*:�OpUoaai) , . . <br /> Gheck e s � /fele box (Check the apptop►isle bWcj <br /> Does the sysE�m vns'�st�vf a seepage piN, ❑Yes �No Q Probed tank�ottom - <br /> ce55D0o1 d Il, r'le� hin �? � " , <br /> I] Observad low If�uid leael <br /> Do s�y sewa a 1a is)leek b�low thAir ❑Yes �'No • <br /> ,desi9ned o�e,�aUa Ih? ' � ❑ ��xaminad construction recobs � <br /> If yea,idenl�ylwhl b sewege , � � Exeman�d empty(pumped}tank <br /> tank leeks. �__ - � , . ❑ Probed ou�ide lar+k fvr'1�leck soil" ' <br /> � Any"yes"An-�n+e rindlcai[as thdt tlre sysiem�5 i�!lFng tiv pratect p p����Yeewm che�k � <br /> grnund w�tar.l ' . <br /> , [] Other ' <br /> � 3eepage pi rn eting�oeo.2090 may be comp{ianl if allvwed <br /> in ordinac�by al permit�ug$uthafty. ' • : -•-•• <br /> "No stantlard oroiocv�exlsts. This lis�is noi exRauslive,in <br /> 'sequen�a►o►der,nardoes ll U7dleQle wihich com6inaUwts ' <br /> ane nacP,�Qsary lo•maRs this det�mineNorJ. <br /> Safety Ch�ck . � , . <br /> 1, Are any m�iM nanee hole covere d�maged,�cracked,or a�oar�d to be structe�rally unsaund� D�'�' �No ` <br /> '2. Were all rr,ai, nance hol�o�uers re��aced in a se�urod man�er(e.g.;all saews raplaoed)? �YQs ❑Mo" <br /> 3. Was secat�d �ecce�rr:sh'av�t pr�es�.'rrt(5ately pan,,secand Cov�r,or saiety netting)-highNy t'ecommended. ❑Ye& [�No • <br /> A�. Wss any o�her /fieallh Issue�af�esenl? • • ❑Yes' �NO <br /> F.xp►a�n: _ ...,...._._ --- . - <br /> t5ystem i�a ImminRnt threat to pubfic healtfi ands,��ry. . � <br /> Certif.icati�n � . . <br /> This fotm�s tn e pleted and atlached to the Sumrnary Form ofthe Nfinnes�ota PolluOon Cantrol Agency's(MFCA)•Ceneplia�ce • <br /> �nspection Fo Exisling Subs�ce S�wageTreatrrient Sysbema.Observe�ona,�interprotalivns,and condu�,ions musl be <br /> completed by n i pector,maint�inet,or service pro�de�.Completed form must be s�bmitfed to the Iocal unit of governmenk a►ifhin <br /> 15 days. ' <br /> . t <br /> � ,�� � <br /> Prvpehy owner�na (s): L�:,�L��-�� � .. � - <br /> pro�e�iyaddre�s: �t�5��.� Ro�a� (�h�� �'1i� Ss�s� � . .-.-� <br /> Propertp own@r�s a dress{if diffv�enti: ' ,r: �.�..�,�...' <br /> Couniy: ,�� � Phon�: 9SZ "Z-�19 - �3� . <br /> 1 hareby cerlf�Ilth 1 persone�lymac�the obse�vetlons, rnte�pretatlo»s,and con�lusions rapo�ted on thls ferm ertd,that t�►ey a�s <br /> correct. <br /> , Name: 'I ' cCercification r�umber. C Y�2� , <br /> Busines5 licens�e n end nWnber. ,� v��t VQ �i�S �)rl�j,'�/ �7'�C�V�GGS l-� Z� ' ar � <br /> Name�f locel ul Il f govemm t: � ...- ' <br /> SignaWre: ' Date: , Z�j— ,�00� �• . <br /> �.....�.�.,r.rNr.oy I COmDIictllCe IRSD�ction Forn1 POl fyCiStflt4 SSTS <br />