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07/19/2011 21:33 7634975011 SPTESTINGINC PAGE 05/09 <br /> Jul 18 11 09;47a Elrriei J,Pelr�fson Co. 763-97�-7217 r.2 <br /> PArcel numbP� __ System stat�rs; �Compllani ❑Noncornpliaht <br /> (as�ecermlrre�l by thls f�orm) <br /> Tank Int�griiy and Saf�ty Complwance -Compliance lnspec�ion Form for E�rfsting SSTS <br /> Compliance Issue#Z af 4 <br /> i�atP,of eb�ervgilon, 7��$��� . _ Rcason Fot obseNation: Palnt oi 5ale � <br /> Thls Form expires on(three yeao�): ����4 <br /> Com�liance questionslcreteria: (Required) uerlticetian Methfld"":(Optional) <br /> [Gheck the sprol;oprlel'e box (Check Fhe eppropnete box) <br /> Daes the system cunslst of e seep�ge pi�', ❑Yas Q No ❑ prohed tank bottam <br /> cess op ol,drYwell,,ocleachin 'Y? <br /> ❑ ob6erved bow liquid level <br /> Do any sewage tank(a)leak helaw their �]Yes �No <br /> designed operatln de th? Q Eu�mined construction recards <br /> If yes, Iderrtify whach � Examined empty(�umped)tank <br /> sewage tank leaks, „__.. ❑ Probed outalde tank For"biack soii" <br /> Any"yes"answerfndlcates t1rAt#Ite�sterry 1s tblNrt�to protect <br /> grourtd water. ❑ Pressuralvacuurn chr�ck <br /> ❑ Othe.r „ <br /> ' 9eepage prts me�Cing�ag0.2550 m�ay b�compllant if alFoWed <br /> in o�dlnance by loeal permittSng eutha�ity. <br /> ".No stendaror/aruMc�of c�xists. 1'his Us!ia not exheuaNve,in <br /> sequentiel oMer,nor does it b?�Jcalo wh�ah combina6vns <br /> ar�nacessary ta mak�fh�;detennrnatrnn. <br /> Sa�Fety Check <br /> 1, Are m�lntenanoe hole cw�rs damaged,ct9ciced,of�+pP�red to be 5truc�urally unsound? 0 Y�" �No <br /> 2. Were malt�tzn�nce ho►e m��rs repl�ced In a socured manner(e.d.,scre�vvs raplaced)? [�Y� ❑No' <br /> 3, Was secondary access resb'aint present�safety pan,second otivar, o�5afe'ly nottlng)–highly recornmended, �Yes Kl�No <br /> 4, Are o1he�sa(ehdheafth issue preAerd? ❑Ycs• QQ No <br /> E�i�ln�, .�.... . .... -- -- <br /> °System Is an Fmminent thl�at to pudlle he�alrh aod saf�ry. <br /> �@11`I�IC$��011 <br /> Thls}arm is to be comp�p�d and ath�Ched to�the Summary Fo�rn o!Ihe MinnesoCe�Pollutlnn Corrhol AgeRcy'�(MpC�t)Gompllan�e <br /> Inspection Form fhr Exlsting 3ubsurface sewage 7reatment 5yst�rns.Obsenr�l�ons, interprelatlnns,and conclusion6 muse be <br /> campleted by an Inspectar, maint8iner, or ssnrice provid�ar.Campketed Fortn must bc submitted te thQ local uni#of gaver�mentwithin <br /> 15 days. <br /> Prope�ly awner name{s�; Scott Winto� � <br /> Properry address; 2140 Gar�iage Lane Wayzata,MN 55391 � <br /> Prope�/owne�s eddres5 (li d{RerEru): <br /> CGunty: I-lennepin Propel'ty awner phone; 952-478-6291 `� <br /> 1 here6y ccrt(fy�hat�personapy mede ff�e obsarvatrons,in0e�,o►etations.and crortelusfons reported on this forrn and that thr�y are <br /> correcf. <br /> �lame; James Qnapgelmann Ceriificatlon number; <br /> Bu�lness license nema�nd number; Elmor J.Peterson Cc�. Llc�ns�218 ���,w ,_„�,.,T or <br /> Name of loc��y�gf go��rnrttent; „_ M. . ...---•— <br /> � Dato: 7�15111 <br /> Signs�ture: �,� _. - ---�---- <br /> ✓� <br /> www.pca.state.mn.us � 651•296�63� • 800-657-��4 - 1'TY 651-282-5332 0�AL1a657-3B64 - Avnllable in al�ernn�iv�formflts <br /> wq-wwlsks�-3'1 • �t/1�3ld9 PCoe 3 of 8 <br />