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Parcel number: <br /> System status: ❑ Compliant ❑Noncompliant <br /> (as determined by this form) <br /> Tank Integrity and Safety Compliance <br /> Compliance Issue #2 of 4 <br /> Date of observation: <br /> 0 Reason for observation: <br /> This form expires on(three ears : <br /> Compliance questions/criteria: (Required) <br /> Check the a..ro.riate box Verification Method**: (Optional) <br /> Does the system consist of a seepage pit*, (Check the appropriate box) <br /> Gess'061, d ell, orleachin. tit? ❑ Yes ❑No <br /> ❑ Probed tank bottom <br /> Do any sewage tank(s)leak below their ❑ Observed low liquid level <br /> desi.ned oaeratinI death? ❑ Yes ❑No <br /> ❑ Examined construction records <br /> If yes, identify which sewage <br /> tank leaks. ❑ Examined empty(pumped)tank <br /> Any"yes"answer indicates that the system is failing to protect El Probed outside tank for"black soil" <br /> ground water. <br /> ❑ Pressure/vacuum check <br /> * Seepage pits meeting 7080.2550 may be compliant if allowed CI Other: <br /> in ordinance by local permitting authority. <br /> **No standard protocol exists. This list is not exhaustive,in <br /> L r 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, cr ckor appeared to be structurally <br /> 2. Were all maintenance hole covers replace i unsound? ❑ Yes* ❑ No <br /> P secured manner(e.g.,all screws replaced)? <br /> 3. Was secondary access restraint present(sa t ,, ❑ Yes ❑No* <br /> y pank,econd cover, or safety netting)-highly recommended. <br /> 4. Was any other safety/health issue present? ��„vvvv ❑Yes ❑No <br /> Explain: 0 ❑Yes* ❑ No <br /> *System is an imminent t at t. .ubliktealth and safety. <br /> Certification 1 Sly ! f U�tis' (El, ` St�`/lC- �.S <br /> This form is to be completed and attached to the Summary Form of t e Minnesota Pollution on Control Agency's /� <br /> Inspection Form for Existing Subsurface Sewage Treatment Systems.Observations, interpretations, and conclusions must be <br /> g y s(MPGA)Compliance <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: J f o® 14.1 <br /> Property owner's address(if different): <br /> County: f£�.4-0. <br /> Phone: <br /> 'hereby certify that l personally made the observations, interpretations, and conclusions reported on this form and.that the <br /> :o hereby <br /> ,�/ y are <br /> Jame: o-.!;al., �l o � �.� <br /> usiness license name and number: lit, 44- Certification number: �� <br /> ame of local unit of government: 0 1C-i it 7e wJ ° ` or <br /> ignature: 6 <br /> Date: �� <br /> wwists4 31 for — <br /> 1/08 Compliance Inspection form FxisilnQ SSTS <br />