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Apr 17 15 09:41a Joseph Olson 763-498-8290 p.5 <br /> Apr.17.20.15 08:56 AM Duane's Septic Service 7634972764 PAGE. 1/ 1 <br /> Parcel number: . System statue: Compliant El Noncompliant, <br /> lag detsnnine , rgg <br /> Tank Integrity and Safety Compliance . St i !, M <br /> . Compliance Issue#2 of 4 - <br /> Date of observation: j±.5.1":______ Reason for observation:. _ • 'Se l{ti L <br /> - This form expires on(three years):- j.(L4- ( • . • <br /> Compliance questlonslcriteria:(Required) Verification Method",":(Optianal) • <br /> JCheck the appropriate box) ' (Check the appropriate box) <br /> • <br /> Does the System consist of aseepage piM, 0 Yes 2(o 7 prod tank bottom <br /> cesspool,drywell,or leaching ph? • <br /> Do any sewage tanks)leak below their. 0 Yes Er/NoObserved tow liquid levet ' <br /> designed operating depth? ' 0 Examined construction records _ • - <br /> If yes,identify which sewage • a Examloed empty(pumped)lank <br /> tank leaks. . <br /> Any"yes"answer Indicates that the system Is failing to protect ❑ Probed-outside tank for"black still' <br /> ground water, . 0 Pressure/vacuum-check _ <br /> Seepage pits meeting 7086.2550 may be compliant if allowed Cl Other: • . <br /> in ordinance by focal permitting authority. - <br /> No ttoo dand protocol exists. This list Is not exhaustive,in• - <br /> . asquentlel order, nor does 11 indicate which oarr►binsrlavis <br /> are neoassary to-inake.this deterinlnatlon.' <br /> Safety Check <br /> 1. Are any maintenance dole covers damaged,cracked,or appeared to be structurally unsound? • 0 Yea"` . j1tb-• ` <br /> •2. •Werealimainlenance hole covers replaced in a secured manner lag.;all.screwe replaced)? .. lZYes 0.Nos" <br /> 3. - Was secondary emcees restraint present(safety pan,second cover,or safety netting)-highly recommended. 0 Yea ego - •• - <br /> 4; Was any other safety/health issue present? • <br /> - . 0 Yes' 2. d- <br /> - Expleln• • • <br /> . <br /> . .'System Is an Imminent threat to pr7b/Ic health and safety- . • - <br /> Certification . <br /> This form Is to be completed and attached to the Summary Form of.tfse Minnesota pailution Control Agency's(MPCA)•Compllnnce • <br /> Inspection Form for Existing Subsurface Sevv*ge•Treatrnent Systems,.Observations,Interpretations,and conclusions must be.. . <br /> vompleted.by an Inspector.maintainer,or service provider,Completed form must be submitted to the local unit of governrnaht within <br /> is days, . <br /> Property owner neme(s): . . . - <br /> Property address: ____ ____72,,S_., �nr Y +L )f g iC C r <br /> Property owner's address hrdifferent): . <br /> • County: . . Phone: - . •• <br /> I hereby certify that I personally made the observations,interpretations,end conclusions naported on this form and that they are • <br /> coireCt. <br /> Name: ,r 4 e-LCher . . Certification number: C..a C) $'1/ <br /> ' Bullhead license name and number. ;.-.)1.1C t7;-i 5p pi-it_ cer yrr,a', L1., - 4,a t/- or <br /> • <br /> Name of local un vemment: • - <br /> Signature: I - - t}ste: -1 y-/ ' <br /> wq wwlsts4•3I . , . Compliance Inspection Form for ExIsting SSTS <br />