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09/30/2010 01:02 7634975011 SPTESTINGINC PAGE 08111 <br /> I f-a un i im u.rwwisun Vo, <br /> 763,972-7217 p,2 <br /> Parcel number. System ststus: ❑Compliant ®Naneornpliant <br /> (as determined by this form) <br /> Tank Integrity and Safety ComplianCO - Compliance Inspection porn tbrExfs*ing SSTS <br /> Compliance Issue#2 of 4 <br /> Date of observation: MID Reason for observation: I Request From Buyer <br /> This form expires on(three years): 9115MO <br /> Compliance questionsicriteria: (Required) Verif r*ioro Method":(Optionor) <br /> heck the Ammorfate box) (Check the appropriate box) <br /> Does the system consist of a seepage pit*, 0a ;I No <br /> cess ool I or leachingIto ❑ Probed tank bottom <br /> Do any sewage tenk(s)leek below their ®Yes jKNc ❑ observed low liquld level <br /> de,sinned=among depth? lC3 Examinedconstruction records <br /> If yes,Identify which ® Examined empty(Pu mppd)tank <br /> sewage tank leeks. 5_1 4,0 p W-, , <br /> Any"yes"snsweribdeates tljat the,9ygtago is ftNay to proms ❑ Probed outside tank for'blaok soil" <br /> groand was ❑ Pressure/vWUUm check <br /> sOOaage pills mewing 7080.Mo may be compliant ff allowed ❑ Cytlner. <br /> in ordinance by local permitting autharity. <br /> '-No standard protocol exists, 7lris list Is not exheusfive,in <br /> sequen9af order,nor door it irr toe wAim eanbinafbns <br /> Sm necessary to make U*deferminedon. <br /> Safety Check <br /> 1. Are maintenance liege covers damaged,craeload,or appeared to be structurally unsound? ❑Yes' No <br /> 2. Were maintenance hole covers replaced in a secured manner(e.g.,screws replaced)? N Yes ❑No* <br /> S. Was secondary access restraK present(sd'ety parr,second cover,or safely netting)_highly recommended. ❑YesNih❑No <br /> 4, Are other se"fttselth issue present? ❑Yes' ®No <br /> E wleln: _ <br /> 'System lk an kni"lnent NVOSt to public health and safory. <br /> Cel"tlflCation <br /> This form Is to be completed and attached to the summary Form of the Minnesota Pollution Cartrol Agency's(MPGA)Compliance <br /> Inspection Fornr for Existing Subsurtsee Sewage Treatment Systems.Observations, Interpretations,and conclusions must be <br /> 1rn <br /> completed by an inspector, aintolner,or service provider.Completed form must be submitted to the local unit of government within <br /> days. <br /> Property owner name(s): Jef Joernes <br /> Property address: 17.5 Truffula Trati Long Lake,MN 55356 <br /> Property owner's address(Irdumrenq; <br /> County: Henrnpin Property owner phone; 6124M&3778 <br /> I hereby oerU&that l perronagy mode the obserslat/ons,infsrprafeUons,and condusions reported on this form and f t they are <br /> correct. <br /> Name: Jarn�Braegelmorin Certification number. _ <br /> Business license name and number. Elmer J.Peterson Co. Uwerrselli 219 or <br /> Name of local orf government <br /> Signature: Date: 822110 --— <br /> WWW.Pca.srnte.mnM. - 651-2%-=O - 800 657-3864; TTY 651.282-5332 or 800.697-3844 . Available in alternative formats <br /> wq•wwists4-3T • 4124109 <br /> Pale 3 of 8 <br />