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07/18/2010 00:03 9527586278 ADVANCED ONSITE INC PAGE 05 <br /> Parcel number: System status: ®Compliant El Noncompliant <br /> (as determined by this form) <br /> Tank Integrity and.Safety Compliance — Compliance Inspection Form for Existing SSTS <br /> Compliance Issue #2 of 4 <br /> Date of observation: July 12,2010 Reason for observation: Property Transfer <br /> This form cxpirce on(three years): July 12, 2013 • <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 ® Probed tank bottom <br /> cesspool, drywell, or leaching pit? - <br /> ❑ Observed low liquid level <br /> Do any sewage tank(s) leak below their 0 Yes ►;1 No <br /> designed operating depth? ❑ Examined construction records <br /> If yes, identify which Z Examined empty(pumped)tank <br /> sewage tank leaks. ❑ Probed outside tank for"black soil" <br /> Any'eyes"answer indicates that the system is failing to protect <br /> ground water. 0 Pressurehvacuum check <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 maintenance hale covers damaged,cracked,or appeared to be structurally unsound? ❑Yes* ® No <br /> 2, Were maintenance hole covers replaced in a secured manner(e.g..screws replaced)? ®Yes ❑ No* <br /> 3. Was secondary access restraint present(safety pan,second cover,or safety netting)—highly recommended. ❑Yes 0 No <br /> 4 Are other safety/health issue present? 0 Yes" ®No <br /> Explain: <br /> *System is an imminent threat to public health and safety. <br /> Certification <br /> This form ie to be completed and attached to the Summary Form of the Minnesota Pnliutlnn 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 /> 16 days. <br /> Property owner name(s): Estate of Diana Gross (Attn: Rich Gross) <br /> Property address: 55 Wear Lane North Orono, MN. 55356 <br /> Property owner's address(if different): (Attn:Rich)721 Bridal Path Trail Hamel, MN. 55340 <br /> County: Hennepin Property owner phone: Rich:1612)865-8598 <br /> /hereby certify liwt I personally made the observations, interpretations, and conclusions reported on this form and that they are <br /> correct. <br /> Name: Thomas KlanchniK Certification number: R 5945 <br /> Business license name and ► •- Advanced OnSite, Inc. L 2656 or <br /> Name of local unit o - •- <br /> Signature: s _ Date: July 17_2010 <br /> wbwv.pca.state.mn.0 651-296-6300 • 800.657-3864 • <br /> TTY 651-282.5332 or 800-657-3864 • Available in alternative formats <br />