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kpr .17 12 05:25p Kathleen 763-497-2764 p.1 <br /> Panel number. System status: Compliant ❑idoncrxnplisnl, <br /> (as dete+ralne 1 <br /> I OW.3 kst pl. <br /> Tank Integrity and Safety Compliance <br /> -st'A�cha <br /> Compliance Issue#2 of"4 <br /> Date of observation: t"- - Reason for observation: ) ' l(M! pe L <br /> This form expires on(three years): <br /> Compliance questioriskriteria: (Required) Verrification Method"":i(Optionai) . <br /> check sire are box (Cheat the appropriate box) <br /> Does the system consist of a-seepage pir, ❑Yes No Probed tank'.bottom <br /> cess old Uor teaN Pit? <br /> Observed low liquid level <br /> Do any sewage'tank(s)leak below their. ❑Yes No <br /> designed operefirith? ❑.-Examined construction records . <br /> If yes.identify which sewage Examined empty{pumped)tank <br /> tank leaks. ❑ Probed,outside tank for"black soil' <br /> Any"yes"answer indicates that the system is fafli}rg to protect <br /> ground water, ❑ Pnessureivacuurn check <br /> Other. _ 3 - l Dr.(9 r a {F ' 1 <br /> ' Seepage pits-meeting 7080.2550 may be compliant if allowed <br /> in ordinance by.local permitting•authorky. <br /> /Wo standard protocol exists.This Ilst Is.not exhausfiva,in <br /> sequential order,nor does It hrdlcate Mich combfnstions - <br /> am necessary to-make.this determination. <br /> Safety Check <br /> i. Are any ma tr4enance hose covers dwywped,.cracked,or appeared to be structurally unsound? ❑Yes" VNO. L <br /> 2. •Were all-maintenance hole covers replaced in a secured manner(e.g.;all-screws replaced)? Yea ©No". <br /> 3. Was secondary access restraint present(safety pan,seo6hd cover.or safety netting)-hfghly recommended- ❑Yes '15j No <br /> 4: Was any othersafelyiheelth Issue present? ❑Y9s' N6 <br /> Explain: <br /> "System Is an imminent threat to pUblic health andsafety <br /> Certffication <br /> This form is to be completed and attached to the Summary Form of.the Minnesota Pollution Control Agency's(MPCA)CompSance <br /> Inspection Form forExisling Subsurface Sewage•TreabheritSystems..Observafians,Interpretations.and conclusions must be.. <br /> completed"by an inspector.maintainer,or service provider.Completed form must be submitted to the local unit of gcimrn rreirt within <br /> 15 days. <br /> 11 <br /> Properly owner name($): _ i ! '� (} t' - ✓�l (. L <br /> Properly address: 1 n,. T��;i �,. ift, .121 -�r.•,� <br /> Property owner's address(If d'sfferentX <br /> County: ! < E✓ iii 1�I P ij'� Phone: <br /> r hereby certify that i personaNy made the observations, interprmistions,and cencfuslons reported on Phis form and That they are <br /> collect <br /> Name: Certification number <br /> Business;license name and number rj_r7jf 'i:'�' or <br /> Name of local un ovemmenf: <br /> Signature: Date: <br /> wp-ww1sts4-3 f Compliance inspection Form for Existing SM <br /> 411011 <br />