Laserfiche WebLink
• <br /> Parcel number: • System status: ompliant 0 Noncompliant <br /> (as determin thl f <br /> fvir LLC <br /> ]X92;:310-Pl. <br /> Tank Integrity and Safety Compliance St. Michael, MN 576 <br /> Compliance Issue-#2 of 4 <br /> Date of observation: 9- Q - C� {Reason for observation: f-tA/Kn- (.7)4490A <br /> This form expires on(three years):- 1 - _! <br /> • <br /> Compliance questions/criteria: (Required) Verification Method**:(Optional) <br /> • <br /> (Check the appropriate box) (Check the appropriate box) <br /> Does the system consist of a seepage pit*, 0 Yes No El Probed tank bottom <br /> cesspool,drywell,or leaching pit? in <br /> - <br /> Do any sewage tank(s) leak below their 0 Yes r_51 No Observed low liquid level <br /> designed operating depth? 0 Examined construction records <br /> If yes, identify which sewage t Examined empty(pumped)tank <br /> tank leaks. , <br /> 0 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 /> _I <br /> nOther: 3 - 1OOo 6u1. CeO/ eaI <br /> * Seepage pits meeting 7080.2550 may be compliant if allowed I <br /> in ordinance by local permitting1tk5'authority. ta, <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 p, <br /> 1. Are any maintenance hole covers damaged,-cracked,or appeared to be structurally unsound? 0 Yes* L7 rvo <br /> 2. Were all maintenance hole covers replaced in a secured manner(e.g.;all screws replaced)? I 'Yes 0 No* <br /> 3. Was secondary access restraint present(safety pan,second cover,or safety netting)-highly recommended. L7 res 0 No <br /> 4. Was any other safety/health issue present? ❑Yes* Ivo <br /> Explain: • <br /> . <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): y'4 `] I nk _- <br /> Property <br /> II ) <br /> address: ( � 0 120 e.6� f(r CYJ I 0 r 0 tl fI / A. - <br /> Property owner's address(if different): <br /> County: n 0,e Phone: <br /> I hereby certify that I personally made the observations, interpretations, and conclusions reported on this form and that they are <br /> correct. <br /> • <br /> Name: LJ j� <br /> u & t2_t � the / Certification number: C-, C� `� <br /> �- �2 <br /> • <br /> Business license name and number: Uri>7�h 5 eft-)c. �P r V i CF, L E�Lr - or <br /> Name of local unit-ot ovemment• 7� p <br /> Signature: ,j� � ' -V, Date: 1 - q _ <br /> wq-wwists4-311 Compliance Inspection Form for Existing SSTS <br /> 4111flR . <br />