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Panel number: System status: Compliant ❑ Noncompliant (as determined y is form) Tank Integrity and Safety Compliance Compliance Issue #2 of 4 c, , Date of observation: ID ( 1 VS ^ Reason for observation: cLt`4✓ This form expires on (three years): .--- —.. -- Compliance questionsicriterla: (Required) Verification Method": (Optional) (Check the appropriate box) (Check the appropriate box) Does the system consist of a seepage pit', ❑Yes KNo 'Probed tank bottom cesspool, drywell,or leaching pit? 0 Observed low liquid level Do any sewage tank(s)leak below their ❑Yes No Examined construction records designed operating depth? If yes,identify which sewage Examined empty(pumped)tank V/P•949 tank leaks. — ❑ Probed outside tank for"black soil" Any "yes"answer indicates that the system Is falling to protect ❑ Pressure/vacuum check ground water. ' ❑ Other: ' Seepage pits meeting 7080.2550 may be compliant if allowed in ordinance by local permitting authority. —-No standard protocol exists. This list is not exhaustive, in sequential order, nor does it indicate which combinations are necessary to make this determination. Safety Check 1. Are any maintenance hole covers damaged, cracked,or appeared to be structurally unsound? ❑ Yes' KNO 2. were all maintenance hole covers replaced in a secured manner (e.g., all screws replaced)? gYes 0 No' 3. Was secondary access restraint present(safety pan,second cover,or safety netting)-highly recommended. ❑ Yes 4. Was any other safety/health issue present? ElYes' *No No Explain: - — — ,.,�.-- 'System is an imminent threat to public health and safety, Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's (MPCA) Compliance Inspection Form for Existing Subsurface Sewage Treatment Systems. Observations, interpretations,and conclusions must be completed by an inspector, maintainer,or service provider. Completed form must be submitted to the local unit of government within 15 days. r� Property owner name(s): �Y ,r9 l r^ Airy ----...... — Property address: / 1'70 IIIZ._ Property owner' address (if different):County: �; Phone: I hereby certify that I personally made the observations, interpretations, and conclusions reported on this form and that they are correct. �,I ,�,�\ (� , ... Name: e� _ ��Ccertification number: CA ?`'1 _„- . _. Business license name and number: - j 01 , VC,... or — Name of local unit 'o'er • c t: I //— `/— -- Signature: f• -,,,.4--) �/, -- - Date: f'F/ tf.” - -- wq•wwists4.3 Compliance Inspection Form for Existing SSTS 4/1/08 Sia/CO 39dd ZTIEEL8Z56 9T :ZT tTI3Z/1713/0t