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Parcel number. Syratem ug: �Comppant ❑Noncomppant <br /> (es det Tned by tMs fam) <br /> Tank Intagrity and Safety CompliancQ-Compllance lnspe tion Forrn for Existing SSTS <br /> Compliance Issue % <br /> Dete oi observa6on: ��4 Reeson for observation: Req t From�wner <br /> This fam expires on(lhree years): 8/5/17 <br /> Compifance quesdondcriterla:(Required) VeHHc on Mefhod"'•(Optlonah <br /> lChedc lhe aanrovrfete box) the appio�pAate box) <br /> Does tt�e system oonaist of a seepege Pit'� ❑Yes �No ❑ Pr terdc bdtom <br /> ce�pss o_o_I,. II or I�chin tt? <br /> Do any sewege tank(a)lealc below their ❑Yes �No � low liq�d IavN <br /> deaicmed oaeradrn�dePth? ❑ miried oonstruction reoorids <br /> If yes.identi(y which � irted emPtY(P�Ped)tank <br /> aewage tank IeakS ❑ oWide tardc for'bfeCk sdl" <br /> AnY�aC'anawx lndkatea that the sy�mm!s Ia�Nng to protect <br /> grorrnd wa[er. ❑ Pr ure/vecutan chedc <br /> ❑ r. <br /> 'Seepege pits meedr+g 7080.2550 mey be complient if allowed <br /> in ordinano9 by locel permiCing authOrity. <br /> ••No sfa p�toopl ex/sf5.7ids/ut is rtof axhaualh�s,in <br /> aaqtnrn al oider,nor does U hidk:ate Mhich carnbfnations <br /> ere n asary to maNe tlNs detemdnetion. <br /> Safety Chetk <br /> 1. Are m�ance hofe covers damaged.aadced�or appeared to be atrucWrolb ❑Yes• ■No <br /> 2 Wae mafMe�ce hde oovers replaced fn a aeased manner(e.9•,saevs 9 �Yes ❑No• <br /> a. was sec«x�s,y acoes8,+�saa�m arasem(s�re�r aan�seoorW oover.or safety netli —highly reWrnmended. ❑Yes ■No <br /> 4. Are ott�er salely/heaHh iseue preseM7 ❑Yes' �No <br /> Expl9in: <br /> 'System!a an JmmJnant thnst to publ/c hwltl�and p!ely. <br /> Certification <br /> This(orm ia to be oompleted and ettedred to the Summary Form of the Minneaofa lutlon Con7ol Agency's(MPCA)Compliancs <br /> Mspectlon Form for Ex�ting Subsurface Sewape 7reatrnsnt Syshms.0 ons,IMerpretatlona,and oondusbru must be <br /> oompleted by an inspecior,meintainer,or service provider.Competed torm muat aubmitted ro the Iocai unit of govemment wRhln <br /> 15 daya. <br /> Property owner neme(s): Jim Olson <br /> prpp�y��; 4360 Bayside Roed Maple Plain.MN 55358 (Orono) <br /> Property owners addreas(tf dlRerenq: <br /> Courqy: Nennep(n property ownu php�e; 12-518�4418 <br /> 1 here6y certily G�at!personaNymada fhe obsenretrbns,iMerpretations,and cond repoRad on!Ms fam and tl�ffi they are <br /> crovect. <br /> Name: 3ames Braegelmann CertlGc�i rnrmber. <br /> Business Ilcense name and numbar: Elmer J.Peteroon Co. Llcenae�F 279 0� <br /> Neme of govemment � — <br /> SiynaWro: p�: 8l5174 <br /> www.pcastate.mn.us • 651-296-6300 • 800•657•3864 • 77Y 651•282-5332 800�657•3864 • Availabk tn altemsdve formets <br /> wq-wwlstz�31 . �/2</09 Page 3 oJ 8 <br /> i <br />