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11/29/2011 18:57 7634988290 RUSTYS PERC TESTING PAGE 04 <br /> Parcel number: System status: ■Compliant ❑Noncomplism <br /> (as determined by We Nrtn) <br /> Took lebgrity and=ably Caepustur.- Colnptisnce Inspection Form for Existing SSTS <br /> Compliance Issue 92 of 4 <br /> Date cf observabon: 10/12/09 Reseon for observation: Property Trenster <br /> This form expires on(three years): 10/12/12 <br /> Compliance questions/cftels:(Required) Verification Method**:(Optional) <br /> LqLWA the a ate box (Check the e <br /> ppnop7isfe box) <br /> Does the system consist of a seepage pit, ❑Yes 0 No <br /> c d I or leachingit? [3 Probed tank bottom <br /> Do any sewage tank(s)leek below their ❑Yes 0 No E3 Observed low liquid level <br /> designed operating depth? ❑ Examined cone action records <br /> 'If yes,identify which Exemined-empty{pumped)tank <br /> sewage tank leaks. �] Probed outside tank for'black soil" <br /> Any"yes"amwerindoatas Uret dere"*rem Is faliling ro <br /> ground wear. protect ❑ Pressure/vamum check <br /> Seepage pits meeting 7060.2550 may be cornplient if allowed ❑ Other: <br /> in ordnance by local perm4ng authority. <br /> No standard protocol exists. This list is not exhaustive,in <br /> sequeofiel orator,nor does K indicate whirl►combinstwis <br /> are necessaryto maim N&oleaannination. <br /> Safety Check <br /> 1. Are maintenance hole covers damaged crocked,or appeared to be structurally unsound? Q Yes" M No <br /> 2. Were maintenance hole covers replaced in a secured manner(e.g.,screws replaced)? S Yes ❑No, <br /> 3. Was secondary access restraint present(safety pan,second cover,or safety netting)—highly recommended. ❑Yes ■No <br /> 4. Are other safetylheallh issue present? ❑Yes' ®No <br /> Explain: <br /> *Syaatar Is an benrinent MnW 10 pubdc h*M M and SOVY <br /> Cor dfication <br /> This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compliance <br /> Inspection Form 1br Existing Subsurraaa Sawape TreaUlmnt Systems.Observations,interrpreMons,and conclusions must be <br /> completed by an inspector, maintainer,or service provider.Completed Dorm must be submitted to the local unit of government within <br /> 15 days. <br /> Property owner name(s): Tim or Dorms Corrigan <br /> Property address: 155 Tndlala TOW tong Lake.MN 53356 <br /> Property owners address(Itdwsrwtt): <br /> County: Nennepn Property owner phone: 952-475-0881 <br /> 1 hereby carbly that 1 personally made the observations,intsrpretdions.and conclusions Worted on this form and that they ere <br /> correct. <br /> Name: James Braegelmarin Certification number; <br /> Business license name and number. Elmer J.Peterson Co. LicenwN 219 or <br /> Name of I unit or gov nt <br /> Signature: per; 10/12109 <br /> —..Pts. .mn.us - 631.296.6300 - 900-6s7-3 T Y 651-262-5337 or af70.657.3564 - Available in alternative formate <br /> q- <br /> wwwfsts4.31 - 4121/09 <br /> Aage 3 of 8 <br />