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05/09/2011 10:05 9528733112 PAGE 03/04 <br /> Parcel number: <br /> System status:Pyy(t�cis <br /> mpliant ❑Noncompliant <br /> (as determined form) <br /> Tank Integrity and Safety Compliance <br /> Compliance Issue #2 of 4 <br /> Date of observation: a1) Reason for observation: <br /> This form expires on(three years): —�- <br /> Compliance questions/criteria: (Required) <br /> Check thea ro rials�epogs` <br /> Vertflcation Method'": (Optional) <br /> Does the system consist of a (Check the appropriate box) <br /> cess ool d II,or leachin ItP ❑YesNo X probed tank bottom <br /> Do any sewage tanks)leak below their ❑Yes KNo ❑ Observed low liquid level <br /> des" redo eratin de t? Examined construction records <br /> It yes,identify which sewage Examined em ) <br /> tank leaks. PtY(pumped)tank <br /> Any"yes"answer indlcafes that the sysfem is failing <br /> ground water. to protect 13 Probed outside tank for"black soil" <br /> ❑ Pressure/vacuum check <br /> Seepage pits meeting 7080.2550 may be compliant if allowed ❑ 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 /> Safety Check are necessary to make this determination, <br /> 1. Are any maintenance hole covers damaged,cracked,or appeared to be structurally unsound? �!, <br /> 2. Were all maintenance hole covers replaced in a secured manner(e.g., all screws replaced)? ❑Yes' Ivo <br /> resent(safety Yes [I No' <br /> 3, Was secondary access restraint <br /> P ( fety pan,second cover,or safety netting)-highly recommended. ❑ Yes <br /> No <br /> 4. Was any other safety/health issue present? <br /> Explain: ❑Yes- Q�No <br /> 'System is an imminent threat to public health and safety. — f <br /> Certification <br /> This form is to be completed and attached to the Summary Form of the Minnesota Polluton Control Agency's(MPGA)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): (� l0 <br /> Property address: <br /> Property owner's address(if different): �-- — <br /> County: - _ <br /> Phone: <br /> coI herebyrrect, certify that I personally made the observations, interpretations,and conclusions reported on this form and that they are <br /> Name: t sWeb, <br /> Certification number; <br /> Business license name and number: Q goal <br /> Name of local unit ofmart _ or <br /> Signature: <br /> Date: <br /> wq-wwisrs4-3 f <br /> 411108 Compliance inspection form for Exisrino SSTS <br />