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10/29/2010 11:29 7634988290 RUSTYS PERC TESTING PAGE 04 <br /> Parcel number. 26.118-23-41-0009 SYatem stems: ®Compliant ❑Noncomphant <br /> (as deftm*wd by th/s form) <br /> Tank Integrity and Sa 4 ty Compliance <br /> Compliance Issue#E2 of 4 <br /> Date of observation: 10/18/10 Reason for observation: transfer <br /> This forte expires on(three years): 10/18/13 <br /> Compliance questiona/criteria: (Required) VerUlcation Me~*: (Optional) <br /> Check the riaUe <br /> (Chace the epprrrp►iete box) <br /> Does the system consist of an-paga pmt", ❑Yes ®No <br /> cess dr <br /> jwell,or ❑ Probed tank bottom <br /> Do any sewage tanks)leak below their ❑Yes C@ No ❑ Observed low liquid level <br /> ® Examined consbuction records <br /> If yes,identify which sewage ❑ Examined empty(pumped)tank <br /> tank leaks. 11 Probed outside tank for"black soiP <br /> Any'�as"answw Urdkatsa OW go sysaun is fs jing to pm bct <br /> ground*Ww. ❑ Pressundvacuum check <br /> Seepage pits meeting 70802550 may be compliant if allowedOther: Maintenance rewrt <br /> in ordinance by local permang auuarity. <br /> "Nb standard palood exists. This ftt is not exhauaw,in <br /> seque WW order,nor does a indicalle Wh;ch combinsUms <br /> ars necessary to make this determination. <br /> Safety Check <br /> 1. Are any maintenance hole covers damaged,cracked,or appeared to be structurally unsound? ❑Yes' ®No <br /> 2. Were all maintenance hole coven replaced in a secured manner(e.g.,all screws rmpiaoed)? Yes ❑No- <br /> 3, Was secondary aocese r9stmint Present(safety pan,second Cover,or safety netting)—highly recommended. ❑Yes No <br /> 4. Was any other safety/health issue present? ❑Yes* ®No <br /> Explain: <br /> ' 'ps ft an Imminent tlueat to public heaft and salW. <br /> Certification <br /> This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPGA)Compliance <br /> Inspection Form for Existling Subsutlacs Sewage Trsabnant Systema.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 /> Ys. <br /> Property owner nan*s): Richard Seitz <br /> Property address: 1.185%ndmere Road <br /> Property owner's address pfdiftenq: <br /> County: Hennepin Phone: It52.645-1005 <br /> I hereby cert that l personally made the obserye6ons,interpretations, and condusians reported on this form and that they ars <br /> correct. <br /> Name: J J.Olson Certification number: 1255 <br /> Business license name and number. Rusyf Olson's soil and perculadon testing 810 or <br /> Name of local unit <br /> Signature: Date: 10/23/10 <br /> wq-ww1sts4-31 Compliance 1 <br /> 414109 nspertion form for Existing SSTS <br />