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05/09/2012 14: 29 9528733112 PAGE 02/05 <br /> Parcel number: ..._ System <br /> umber: System status: Compliant ❑ Noncompliant <br /> (as determined y is form) <br /> Tank Integrity and Safety Compliance <br /> Compliance Issue # of J` <br /> Date of observation: 9 l� Reason for observation: __a <br /> _This form expires on (three years): - . <br /> Compliance questionslcriteria: (Required) <br /> Verification Method": (Optional) <br /> (Check the appropriate box) — (Check the appropriate box) <br /> Does the system consist of a seepage pits, ❑ Yes Xjlo ❑ Probed tank bottom <br /> cesspool, drywell, or leaching pit? <br /> 0 Observed low liquid level <br /> Do any sewage tank(s) leak below their 0 Yes X....NoIiiK Examined construction records <br /> designed operating depth? <br /> If yes, identify which sewage Examined empty(pumped)tank <br /> tank leaks. 0 Probed outside tank for"black soil' <br /> Any"yes"answer indicates that the system is falling to protect <br /> 0 Pressure/vacuum check <br /> ground water. ' <br /> 0 Other: <br /> ' Seepage pits meeting 7080.2550 may be compliant if allowed <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? 0 Yes' KNo <br /> 2, Were all maintenance hole covers replaced in a secured manner(e.g., all screws replaced)? WYes ❑No' <br /> 3. Was secondary access restraint present(safety pan, second cover,or safety netting)-highly recommended. ❑ Yes ANo <br /> 4. Was any other safety/health issue present? <br /> ❑ Yes' 4No <br /> Explain: _ _, --- _. ,------ <br /> 'System is an imminent threat to public 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): ` 1 --- � -. -- <br /> Property address: , 9765-- ri_t� c U - — - <br /> Property own rr,,s address (if different): — `— <br /> County: 1� 1 Phone: _ <br /> J_1 <br /> I hereby certify that l personally made the observations, interpretations, and conclusions reported on this form and that they are <br /> correct. ` ,( <br /> Name: 1- S\ S `Unc L - Certification number: 9Zt�S -- __. <br /> Business license name and number: k, c S 1 r'L. - a'SO -_... _ or <br /> Name of local unit of . ernm_• : - '- —_.. <br /> Signature: /_ Date: <br /> 7(7 j07—___ .,__ <br /> -, 141 Compliance Inspection Form far Existing SSTS <br />