2009 - compliance inspection form (SSTS)

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04/18/2009 14:30 7634988290 RUSTYS PERC TESTING PAGE 04 Parcel number: 33-118-23-41-0007 System status: ® Compliant ❑ Noncompliant (as determined by this form) Tank Integrity and Safety Compliance Compliance Issue #2 of 4 Date of observation: 4/09/09 Reason for observation: Property Transfer This form expires on(three years): 4/09/12 Compliance questions/criteria: (Required) Verification Method": (Optional) (Check the appropriate box) (Check the appropriate box) Does the system consist of a seepage pit', ❑Yes ❑ No ❑ Probed tank bottom cesspool,drywell,or leaching pit? Do any sewage tank(s) leak below their 0 Yes ❑No ❑ Observed low liquid level designed operating depth? ® Examined construction records If yes,identify which sewage 0 Examined empty(pumped)tank tank leaks. _ Any"yes"answer Indicates that the system Is failing to protect CI Probed outside tank for"black soil" ground water. ❑ Pressure/vacuum check Seepage pits meeting 7080.2550 may be compliant if allowed ❑ Other: in ordinance by local permitting authority. No standard protocol exists, This list is not exhaustive,in sequential order, nor does N 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' ® No 2. Were all maintenance hole covers replaced in a secured manner(e.g.,all screws replaced)? ®Yes 0 No' 3. Was secondary access restraint present(safety pan,second cover,or safety netting)—highly recommended. 0 Yes 0 No 4. Was any other safety/health issue present? 0 Yes' 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. Property owner name(s): Foreclose Property address: 2550 Woodhaven Drive _ w Property owners address(if different): County: Hennepin Phone: I hereby certify that I personally made the observations, interpretations, and conclusions reported on this form and that they we correct Name: Joseph J.Olson Certification number: 1255 Business license name and number: Rusty Olson's soil and rculation testin Lic#810 or Name of local unit of government: City n Orono Signature; Date: 4/09/09 wq-ww sts4-31 CornDlinnry/ncnortrnn Fnrm Few C..:,+J....ccx