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02/06/2009 10:19 7634275934 SYSTEM SOLUTIONS PAGE 04 <br /> System status: Compliant ❑Noncompllefrt <br /> Parcel number: (as determined y this form) <br /> Tank Integrity and Safety Coimpllanee <br /> Compliance Issue #2 of 4 <br /> Dale of observation: <br /> Reason for observation' <br /> This form expires on(three years): <br /> Compliance questlons1criterla: (Required) Verification Method":j0ptioneo <br /> Check the apeNristo box (Check the approprfate box) <br /> Does the system consist•of 4 seepage pit', ❑Yes No ❑ Probed tank bottom <br /> cess ool d ell•or•leschin its ❑ Observed low liquid level <br /> Do any sewage lenk(s)leak below their ❑'Yes No <br /> [1 Examined constructivtl records <br /> designed operatin do 31h? <br /> Examined empty(pumped)tank <br /> If yes,identify which sewage <br /> tank leaks. ❑ Probed outside tank for"blac'k soli" <br /> Any"yes,,answer Indicates that'the system Is failing to protect ❑ Pressurelvacuum check <br /> ground water. Ir <br /> (�Other: =�=i7 <br /> Seepage pits mdeting 7080.2550 may be compliant tf allowed F <br /> in ordinance by local permitting authority. <br /> •'No standard protocol axis($. This list is.not®xhausfive,in <br /> sequential order,nor does It Indicate which combinations <br /> are necessary to•inake this determination. <br /> Safety Check <br /> 1. Are any maintenance hole covers damaged,•cracked.or appeared to be structurally unsound? ❑Yes' �N6 <br /> 2. Were all me!nlenance hole covers replaced In a secured manner(e:g.;all screws repleced)7 .0Yes ❑No'• <br /> 3. Was secondary access restraint present(safety pan,see6hd cover,or safely netting)—highly recommended. ❑Yes N' <br /> 4. Was any other solely/health issue present? ❑Yes, Nd <br /> Explain: <br /> *System Is an Imminent threat to public health and Safety. <br /> Certification <br /> This foim is to be completed and attached to the Summary Form of the Minnesota Pollulion Control Agency's(MPCA)'Compllance <br /> Inspection Form for Existing Subsurface Sewage.Treatment Systems.Observations,interpretations,and conclusions must be <br /> completed by an inspector,maintainer,or service provider.Completed form must be subndtted to the local unit.of government within <br /> 15 days, <br /> Property owner nome(s): 4 ' <br /> Property address: 2.Q ,J <br /> Property owner's address(if dllie nt): <br /> County: Phone: <br /> I hereby certify that I personalty made the observations,interpretations, and conclusions reported on this form and that they are <br /> correct. V1C HAGENAN. Phone: 763-427-5934 <br /> Name: <br /> _ SYSTEM SOLUTIONS_._.1523.1 Jackel St. NW-- <br /> Business license name and nur MYCA#1483 Ranasey, MN 55303 _ ? or <br /> Name of local unit of governmenl: <br /> COX <br /> _,�VA 0 <br /> Signature: Date: <br />