Laserfiche WebLink
04126/2010 07:28 9528733112 PAGE 03I65 <br /> � -� - ° <br /> Parcel number: A w <br /> __._. „ ^ _ � System status: ��mpliant [�Noncompliant <br /> (as detemrined by this form) <br /> Tank integrity and Safety Compllance <br /> Compliance Issue #2 f 4 ti ' <br /> � <br /> Date of observation: �_ `�. � ^(�_ Reason for observation: � <br /> This form expires on (three years): T ~ <br /> Compliance questionslcriteria: (Required) Verlfication Method"*: (Optional) <br /> (Check the approprlete boxJ (Check the appropriate box) <br /> Does the system consist of a seepage pit", ❑ Yes �No ❑ Probed tank bottom <br /> cesspool,drywell,vr leaching_pit? <br /> Do any sewage tank(s)leak below their ❑Yes No ❑ Observed low liquid level <br /> . designed operatin de th7 �� � �Examined constructlon records <br /> If yes, identify which sewage �Examined empty(pumped)tank �;��r,7���' <br /> tank leaks. ❑ Probed outslde tank for"black soil" <br /> Ar1y"yes"a�swar lnd/cates thaf the system Is faflJng to profecf <br /> ground water. • Q Pressure/vacuum check <br /> ❑ Othe�: <br /> ' Seepage pits meeting 7Q80_2550 may be compfiant if allawed ����-- -� <br /> In ordinence by Iocal permitting authority, <br /> ••No standard protoco!exists. this list is npt exhaus�ive, in <br /> sequential orde�,nor does it indicate which combinations <br /> a�e necessery to make this detorminalion. <br /> Safety Check <br /> 1. Are any maintenance hole covers damaged,cracked,or appeared lo be structurally unsound? ❑ Yes' �No <br /> 2. Were all maintenance hole covers replaced In a secured manne►(e,g„ all screws replaced)? Yes � <br /> � ❑ No� <br /> 3� Was secondary access restraint prese�t(safely pan, second cover,or safety nett�ng)-highly recommended. ❑ Yes �No <br /> 4, Was any other safety/health issue present? ❑ Yes' [��No <br /> Explain: r <br /> •System �s an lmminent threat t�o publlc heallh and safetj+. ~ � �� <br /> Certification <br /> This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's (MPCA) Compliance <br /> Inspection Form for Existing SubsurFaee Sewage T�eatment Syatems.Observations, interpretations, and conclusions must be <br /> completed by an inspector, m2intainer,o�service p�ovfder. Completed form must be submitted to Che local unit of govornmenl wlthin <br /> 15 days. <br /> / • <br /> Property owner name(s): ` � <br /> �- <br /> Propertyaddross: �(� �� � v r- (� ���/('� <br /> Property owner's address (if o�fferent): <br /> County: �('�r���� �` �r� Phone: <br /> 1 hereby cBrtify that I personally made the observations, lnterpretations, and concluslons reported on thrs form and that they are <br /> correct. � <br /> �.S'n Sc���1 Ul�d _� ) <br /> Name: Certification number: �"`��(pJr__ __� _ <br /> Business license name and number; �,�� ,1 �1 � • 1(Q,5_ __�,�'1 L �NC�.,,_ _ or <br /> Name of local unit vernm . �� <br /> Signature: � i � <br /> _ �ate: <br /> � . . -�-�. <br /> wq•wwrsCs4-31 Complion[e Inspectron Form jor Existino, SSTS <br />