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<br /> Parcpl number _ Sy tem status; Compliant ❑ Noncompliant
<br /> � (a determined y hrs farm)
<br /> Tank In�egrity and Safety Compliance
<br /> Compliance issue #� of 4
<br /> Date of observatfon: I J� Q� Reason for observatlon: �(,C� .._,_,,.,."..,_.,_._, ..„__._
<br /> This form expires on (three yea�s): _�,.,,,,,,,, ,�_, __ ^
<br /> Compliance questions/c�iteria: (Required) erification Method": (�ptional)
<br /> Check the a ro riafe box (Check the eppropriate box)
<br /> Does the system consist of a seepage pit', ❑ Yes [�(Vo ❑ Probed tank bottom
<br /> cesspool,drywell, or leachingpit?
<br /> ❑ Observed low liquid level
<br /> Do any sewage tank(s)leak below their ❑Yes �No
<br /> desi ned a eratin de th? Examined cvnstruction re�ords
<br /> I�yes, identlfy which sewage �Examined empty(pumped)tank
<br /> tank leaks.
<br /> _ ❑ Probed outside tank for"black soil"
<br /> Any"yes��aAswer rnd/ca�es thae the system is faflJng to protect
<br /> ground wafer, � ❑ Pressurelvacuum check
<br /> ❑ Other: ___ .
<br /> ' Seepage pits meeting 7080.2550 may be compliant if all�wed '
<br /> in ordinance by local permitting authority_
<br /> � No standard profocol exists. This list is nof exhaustive, in
<br /> sequentia!order, nor does if indicate which combinations
<br /> are nec�ssary to make this determination,
<br /> Safety Check
<br /> 1. Are any maintenance hole covers damaged,cracked,or appeared to be st cturally unsound? []Yes' �No
<br /> 2. Were all maintenance hoie covers replaced In a secured man�er(e.g., all crews replaced)? �Yes ❑ No'
<br /> 3, Was secondary access restraint present(satety pan, second r,over,or saFe y netting)�highly recommended. ❑ Yes �No
<br /> 4. Was any other saFety/health issue present? ❑ Yes' ,�No
<br /> 6xplain;
<br /> *System is an imminent lhreat to publlc hea/th and safpty.
<br /> Certification
<br /> This form is to be completed and altached to the Summary Form of the Mln esota Pollutlon Control Agency's (MPCA)Compliance
<br /> Inspection Form for Existing Subsurface Sswage Treatmant Systems, bservations, interpretations, �nd conclusions must be
<br /> completed by an inspector, maintainer,or service provider. Completed form musl be submitted to the local unit of govErnment within
<br /> 15 days.
<br /> Property owner name(s): �pl�lQ � _ ___ __ _
<br /> .
<br /> Property address: � ,_, - �.M...._..._...._....._ _
<br /> Property owner's address(ifdffferent)�
<br /> County: /Il i�. Ph ne_ ��.. .,___---- ..-- --. .
<br /> I hereby cenify ihat I personafly made the observations, lnterpretations, and conclus/ons nepoRed on this fvrm and ihat ihey are
<br /> correcl, ,
<br /> Name: ��� �Q��UI�CJ ._,_ C rtification number, ��j�_„__ ___
<br /> Business license name and number: ��Q.U__.IS.:L��U\ 5 Q�_-- -- .._. or
<br /> Name of local unit of v rnm .
<br /> Signature: _� Date: �/
<br /> _.. — _..���_ ._�_._
<br /> iun.,.�.ii.r�A ?i - .. . .
<br />
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