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Sep 01 11 10:OOa Elmer J.Peterson Co. 763-972-7217 p.2 Parcel number. p 0 Noncompliant System status: Compliant (as determined by this form) Tank Integrity and Safety Compliance-Compliance Inspection Fomt for Existing SSTS Compliance Issue#2 of 4 Date of observation: 8/25/10 Reason for observation: Point of Sale This form expires on(three years): 8/25/13 Compliance questionsfcriteria:(Required) Verification Method"•:(Optional) (Check the appropriate box) (Check the appropriate box) Does the system consist of a seepage pit, i ❑Yes ®No cesspool,drywe9,or leaching pit? ❑ Probed tank bottom Do any sewage tank(s)leak below their ,❑Yes ®No ❑ Observed low liquid level designed operating depth? 0 Examined construction records If yes,identify which MI Examined empty(pumped)tank sewage tank leaks. ❑ Probed outside tank for'black soir Arty"yes"answer indicates that Ore system is failing to protect ground water. El Pressure/vacuum check ❑ Other: ' Seepage pits meeting 70802550 may be compliant if allowed in ordinance by local permitting authority. "No standard protocol exists.This list la not exhaustive,in sequential order,nor does k indicate which combinations are necessary fo make this determination. Safety Check 1. Are maintenance hole covers damaged,craclmd,or appeared to be structurally unsound? ❑Yes' ®No 2. Were maintenance hole covers replaced in a secured manner(e.g.,screws replaced)? a Yes 0 No" 3. Was secondary access restraint present(safety pan,second cover,or safely netting)-highly recommended. ❑Yes N I t]No 4. Are 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): Bridget Hust Property address: 820 Old Crystal Bay Road S.Wayzata,MN 55391 Property owner's address(if different): County: Hennepin Property owner phone: 952-475-2054 I hereby certify that t personally made the observations.interpretations,and conclusions reported On this form and that they ars correct. Name: James Braegeimann Certification number. Business license name and number. Elmer J.Peterson Co. License#219 or Name of I government Signature: Date: 8/25/10 www.pca.state.mn.us • 651-296-6300 • 800657-3864 • TTY 651-282-5332 or 800-657-3864 • Mailable in alternative formats wgwwr#s4-31 • 4/24109 POW 3 of 8