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0912312011 15:52 9528733112 PAGE 03I05 <br /> Parcel number: .__ _ Syst m status: Comptiant ❑ Noncompliani <br /> -- � (ss etermined y t is form) <br /> Tank Integrlty and Satety Compliance , <br /> �ompliance Issue #? f 4 <br /> Date of observation; � Reason for observation_ , _ _�,___ <br /> This form expires on (three years): - ' � � <br /> Compliance questions/criteria: (Requlred) <br /> V rification Method'''": (Optional) <br /> _�(Check the a ro riate box (Check the eppropriate box) <br /> Does the system consist of a seepage plt'. ❑Yes No � Probed tank bottom <br /> cess ool,d ell, or leachin it? ❑ Observed low liquid level <br /> Do any sewage tank(s)leak below thei� ❑Yes No Examined�onstruction records <br /> designed o eratin de th? um ed tank <br /> -- Examined empty(p P 1 <br /> If yes,idenUfy whlch sewage <br /> tank leaks. ❑ Probed outside tank for"black soil" <br /> Any"yes"a�rswer indicates fhat the syatem Fs faiNng to p�otecf � Pressurelvacuum check <br /> ground wd�er. ' ❑ Other_ ••-- <br /> * Seepage pits meeting 708�.2550 may be compliant if allowed _ <br /> in ordlnance by local parmitting authority. <br /> ' No standard protocol exists. This list is not exhauscrve, rn <br /> sequentral order,nor does it indicate whlch combinations <br /> are necessery to make this determination. <br /> Safety Check � <br /> 1. Are any maintenance hole covers damaged,cracked,or appeared to be st ucturally unsound? �es' No <br /> 2, Were 211 maintenance hole�overs replaced in a secured manner(e.g„ all crews replaced)? Yes ❑ No' <br /> 3. was secondary access reslraint present{safety pan,second cover,or saf ty netting)-highly recommended. ❑Yes No <br /> ❑ Yes' No <br /> 4. Was any other safety/heallh issue present? <br /> Explain: ---• -- �--- ... <br /> 'System fs an imminent lhreat to publlc hea/th and safety. <br /> Certification <br /> This foRn is ta be completed and attached to the Summary Form of the Mi nesota Pollutlon 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 servic�provider, Completed for must be submitted to the local unit of government within <br /> 15 days. / �el! G� _._ � --- <br /> Property owner name(s): � - <br /> �^ _ - -- <br /> Property address: � <br /> P�operty own r's address(if ditfe�ent): ' � <br /> County, ��",�,�,' ,� hone: ,. _—�— —� <br /> f hereby cerfify fhat!personally mede the Observetfons, +nterpretations,a d conclusrons reporled on thls lorrr►and fhat they are <br /> correcf. <br /> Name: _, �� Certification number; ���, _ _______ <br /> � <�.�,� _ or <br /> Business license name and number: -.��.J1. �-- <br /> Name of local unit ove ent: .'—,�7-."" ' '- <br /> Signature: _ �, Oate: _, �v ��_., — <br /> _ .. . . ---'-- .-_„_ s.,. r..r�.:..,, cc-rc <br />