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10/15/2009 16: 15 9528733112 PAGE 03/05 <br /> Parcel number: - System status: ' Compliant ❑ Noncompliant <br /> (as determined by this form) <br /> Tank Integrity and Safety Compliance <br /> Compliance Issue #2 ofq 4 r <br /> Date of observation: 10 l14 9 Reason for observation: c4i, <br /> This form expires on (three years): <br /> Compliance questions/criteria: (Required) Verification Method': (Optional) <br /> (Check the appropriate box) ,. (Check the appropriate box) <br /> Does the system consist of a seepage pit', ❑ Yes 'No 0 Probed tank bottom <br /> cesspool, drywell,or leaching,pit? <br /> Do any sewage tank(s) leak below their ❑ Yes NI No El Observed low liquid level <br /> designed operating depth? 0 Examined construction records <br /> If yes,identify which sewage gz Examined empty(pumped)tank <br /> tank leaks. <br /> ❑ Probed outside tank for"black soil" <br /> Any"yes"answer indicates that the system is failing to protect <br /> ground water. 0 Pressure/vacuum check <br /> ❑ 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? ❑ Yes' NI 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 X No <br /> 4. Was any other safety/health issue present? ❑ Yes' 04 No <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): �l tel S U S'n Sotr q 5 6y�!1.., c-- - r <br /> Property address: A50 LC4r t YC1� ) ono na4 /VIN S ?5jL - -- - <br /> Property owner's address(if different); <br /> County: y`„ Phone: <br /> 1 hereby certify that I personally made the observations, interpretations, and conclusions reported on this form and that they are <br /> correct. �`� 1 <br /> Name: �t�\ �J.�' AUf\C Certification number: RIC95 <br /> Business license name and number: , \Uto (,pS In C. . 050 - or <br /> Name of local unit of governTri : .49 <br /> �l�/f I <br /> Signature: '► A �i Date: 0 <br /> wq-wwisrs4-31 Compliance Inspection Form for Existing 5STS <br />