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05/08/2009 14:20 9528733112 PAGE 08/09 <br /> Parcel number: — System status: Compliant ❑ Noncompllant <br /> (as defermined)y f fs form) <br /> Tank Integrity and Safety Compliance <br /> Compliance IssuA#24&, <br /> ' <br /> Date of observation: Reason for observation: LLI <br /> This form expires on(three years): <br /> Compliance questions/criteria: (Required) VerMeation Method": (Optional) <br /> Check the appropriate box <br /> (Check the appropriate box) <br /> Does the system consist of a seepage pit', ❑Yes J+lo ❑ Probed tank bottom <br /> cesspool,dD=ell,or leaching nit? <br /> Do any sewage tank(s)leak below their ❑Yes No Observed low liquid level <br /> designed operating depth? xamined construction records <br /> If yes,identify which sewage xamined empty(pumped)lank <br /> tank leaks. 9: <br /> ❑ Probed outside tank for"black soil" <br /> Any'Ws"answer Indicates that the system Is failing to protect <br /> ground water. ❑ Pressurelvecuum check <br /> Seepage pits meeting 708.02550;may be compliant if allowed Q Other. <br /> in ordinance by local permitting authority. _ <br /> •*No standard protocol exists. This list is not exhaustive,in <br /> sequential order,nor does it indicate which combinations <br /> are necessary to make this determination. <br /> Safety Check <br /> 1. Are any maintenance hole covers damaged,cracked.or appeared to be structurally unsound? ❑ Yes' A No <br /> 2. Were all maintenance hole covers replaced in a secured manner(e.g.,all screws replaced)? Yes ❑ No' <br /> 3, Was secondary access restraint present(safety pan,second cover,or safety netting)-highly recommended. ❑ Yes No <br /> 4. Was any other safetyihealth issue present? Cl Yes' No <br /> Explain: <br /> 'System is an Imminent threat to pubilc health and safety. <br /> Certification <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 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 submitted to the local unit of government within <br /> 15 days. <br /> Property owner name(s): _- <br /> Property address: <br /> Property owner's address(if different): <br /> County: ,��/��-- Phone: "_-- <br /> I hereby certify that I personally made the observations, interpretations,and conclusions reported on this form and that they are <br /> correct. <br /> Name; Certification number: 1p _ <br /> Business license name and number: U I-% I1t_ '} � or <br /> Name of local unit ver t: <br /> Signature: Date: 91, <br /> wq-ww1st't4 Compliance Inspection Form for Existing 5STS <br /> 411108 <br />