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• <br /> • <br /> • :Parcel number: 3 /1/ $ 3 3 /00G 5 System status: ❑ Compliant ®,Noncompliant <br /> (as determined by this form) <br /> Tank integrity and Safety Compliance <br /> Cclnpllance Issue #2 of 4 <br /> Date of observation: -2, Zi• C/ i;e :;u iv .,Uservation: 5 El._k,i ttii <br /> This roan expires on (three years): <br /> Compliance questions/criteria: (Required) Verification Method": (Optional) <br /> the appr9pniale box) (Check the appropriate box) <br /> Does the system consist of a seepage pit', D Yes t o ® Probed tank bottom <br /> _cesspool, drywell, or leaching pit? —� <br /> ❑ Observed low liquid level <br /> Do any sewage tank(s)leak below their ❑ Yes LK No <br /> designod operating depth? 54 Examined construction records <br /> P "If yes, identity which sewage ❑ Examined empty (pumped) tank <br /> f tank leaks. <br /> -- ------- ---- - -- - ❑ Probed outside tank for"black soil" <br /> Any "yes"answer indicates that the system is failing to protect ❑ <br /> ground water. Pressure/vacuum check <br /> ❑ 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 nut exhaustive, in <br /> sequential order, nor does it indicate which combinations <br /> are necessary to make this determination. <br /> Sarty Check <br /> 1. Are any maintenance hole covers damaged, crackea, ur appeared to be structurally unsound? ❑ Yes' No <br /> 2. vVere all maintenance hole covers replaced in a seem u manner (e.g., all screws replaced)? Q Yes D No' <br /> • <br /> 3. Was secbnuary access restraint present (safety pan• sewna cover, or safety netting)-highly recommended. ❑ Yes l No <br /> 4. Was any other safety%health issue present? $J Yes' %I Nu <br /> i:xplain: AZ-4 3 Moks Af.L C‘V Ll. Atop NE. ED I rn 1 FD' 4-T t ---p u t>1 <br /> *System is an imminent threat to public health and safety. <br /> Certification <br /> This twin 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 /> tt, <br /> Property uwner name(s): (.„.) J_ ivy; -Ei)-&TOR:R: <br /> Property address: ?� G fly (moi v u �C/N�F ��/�j��E P.< i, hJ (J/ os.G� /41`V <br /> Property owner's address(if different): 7�� <br /> County: 6/UN- _ --- -- -- Phone: 0 • • <br /> it/ 2 Vey - 9t/ 3`K- <br /> f nuneby cellar tat I personally made the observations, rt;rorpretations, and conclusicins reported on this form and that thwy o,v <br /> COrr,:Ct <br /> Nanta: dais- <br /> Certification number: / -7 -2-? <br /> Dusiness license name and number: c.(' N' 'S Sc:-/G- "roc" 5 7/4-47 / /- j r <br /> N,,ine of local unit v nment: C1'./7 r ' t cvevw,-, <br /> Signature: c/-!: a c ,L _ -- - Date: V2,' 'e-c:f/ <br /> wq-wwists4-3I Compliance Inspection Form for Extsrinj SSTS <br />