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05/19/2011 20:56 7634975011 SPTESTINGINC PAGE 06/091' <br /> Nov.19.2009 03:14 PM ELMER J PETERSON CO 7639727217 PA=. 2/ 2 <br /> Parcel number, System status: ®Complont ❑Noncompllani <br /> (es detenMnad by this&M) <br /> Tank Integrity and Safe"Compliance- Compliance Inspection Form for SSTS <br /> � tIM �Y <br /> Compliance Issue#2 of 4 <br /> Daw of observation: 5I1I09 Reason for obeotvaGon: Point of t3ale <br /> This form wrpires on(three years); 611112 _ <br /> Compliance questione/arltedo:(Required) VW11111 nttlon Mdhod"':(Optional) <br /> (Check the flpproprlde box) (Check the appropriate box) <br /> Does the system consist of a seepage pit', [7 Yes No ❑ Probed lank bottom <br /> aesagool drywall.or leachln <br /> Do any sewAge tank(s)leak below their ❑Yes No Q Observed low liquid level <br /> d_�,ned opeWinp depth?_ ❑ axpmined construction records <br /> If yes,Won*which Examined empty(purred)tank <br /> sewage tank leaks. ❑ Probed outside tank for"black eoll' <br /> Any"y *"answer Indkates tram rho eysfem to fft f to protect <br /> groundwow. ❑ Pressure/vacuum check <br /> • seepage pita meeling 7000.2530 may be compliant 9 allowed ❑ Other <br /> in ordinance by local pemlHfing authority. <br /> ,•ft stenderd Protocol gists.This Ilat to not exhnuolvo,In <br /> oequenftl ender,nordoaa 5 k4aaft Wft combirWons <br /> are necessary to make this deformft9w. <br /> Safety Check <br /> I. Are maintenance hole covers dariAged,cracked,or appeared to be structurally unsound? ❑Yeo" No <br /> Z Mre maintenance hole covers replaced In a secured manner(e.g.,screws replaced)? N Yes []No' <br /> 3, Was secondstry access restraint present(safety pan,Wcond cover,or safety rietYng)-highly recommendod. ❑Y* [J No <br /> 4. Are other s*W/health Issue present? ❑Yes' ®No <br /> Explain: — <br /> "System YW len Mmfinant torsed to public b"Ah and safety. <br /> Certification <br /> This form in to be completed and attached to the Summery Form of the Minnesota PolluNOA Control Agency's(MPGA)Compliance <br /> Inspection Form for ftlsang Surbtwrface Sewage Tmmmant Systems.Observations,Inlerprelations,and conclusions must be <br /> completed by an inspector,nleinteinor,or serAco provider,Completed form must be submitted M the local unit of government wllhln <br /> 15 days. <br /> Property owner neme(rt): James or Diene Runty <br /> Property address: 220 WakAsid Rd. Orono,MN 55391 <br /> Property owner's address pf ditferenty ^ <br /> county: Hannepin.,. __ Property owner phone: 992.473.0261 <br /> I hereby certll)r that I pmnally made the obseryakons,Interprial'shons,and oatdustons repMed on this farm and that they are <br /> correa. <br /> Name: Jernes Brce elf mann Certification number. _ _ - <br /> Business license name and number. rimer J,Peterson Co. Uwmo#210 or <br /> Nemo of toZ25,0" <br /> mment <br /> y YI I <br /> Signature: Dale, 11119/09 <br /> wwrr.pca. a-mn,us • 651.7.96.6300 . 800.657.3864 TTY 651.282.9332 or 800.657-3861 • U411ableth atten'M'�ttve format <br /> wq uiwirts4-!1 4121/09 pose 3 a�8 <br />