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06/27f2069 12:39 7634988290 RUSTVS PERC TESTING PAGE 04 <br /> Parcel number. 8ystem stetue: �Compllent ❑Noncompli�nt <br /> (es determined by this farm) <br /> Tank Intagrity and Safety Con�pllanco <br /> Comp(fance Issue i�2 of 4 <br /> Dete of observativn: 6R6/OB Reeson fo�observetlon: Propert�!Trenefer „, <br /> This fom►expires o�(threc years): 6l26/12 <br /> Compllance quest�onslcrite�ia: (Required) Verlficadon Method'": (optional) <br /> (Check the app%�riet�e box (Check the appropAete box) <br /> Does the system oonsist of a seepage pit', ❑Yes �No � probed tank bottom <br /> cesspool,drywell,or leecfii�g._pit? <br /> - " ❑ Observed low liquid level <br /> Do a�y sewage tank(s)leak below their ❑Yes � No <br /> desf ned o retin de th? � � Exemined construction reoords <br /> If yes, Identiiy which sewege ❑ Examined empty(pumpedj tsnk <br /> tank leaks. ❑ Probed outside tank for"black soil" <br /> Any"yes"ensnrerind/catea that the aystem!s felling to protsct <br /> 9���� ❑ PressureNacuum check <br /> p Other: <br /> • Seepape pits meeting 7090.2550 may be complianl if allowed � <br /> in ordinanoe by local permitling authorfty. •— -- <br /> "No stenda�d p+vtac�ol exists. This list r's not exheusfive,in <br /> sequenUel order,nor does It indicate which combJneGona <br /> are necc�ssery to make tM8 determinatwn. <br /> Safety Check <br /> 1. Are eny maintenance hale covers damaged,crecked, o�appeared ta be Bt►ucturallr unsound7 ❑Yes' �No <br /> 2. were all maintenance hole covers replaced in e secured manner(e.g.,all screws replaced)� �Yeg ❑ No' <br /> 3, Was secondary acoeas restrelnt proaenl(satety pan,second oover,or sefety netting)—hiphly recommended. ❑Yes � No <br /> 4. Was any other safety/health iseue present? ❑Yes* �No <br /> Explain: <br /> 'Syst�m�s an lmmfnent dtreat to publlc haakh snd sFfaty. <br /> Certification <br /> This form i�to be complebad and attached to the Summary Form of the Minnesota Pollutfon Control Agency's(MPCA)Compliance <br /> Inspection FOrm fcr Exlsting Subsuriace SQwage TreatrneM Sy8berms.Obeervations,interpretations,�nd canclueione must be <br /> completed by an inspeCtor,mafntaine�,or servioe provlder. Completed fonn must be submiKed to the local unit of govemment within <br /> 15 days. <br /> Property owner name(s): Catherine Jnhnsion <br /> Property address: 840 Brown Road S Orona MN 55381 <br /> Propert�r owner's eddrese(�Fdilfererrt): <br /> County, Mennepin Phone: 612-770-1799 <br /> 1 hereby ceRify that 1 pe�sonelly made H�e obseiva6ons, interpieta6ons, and cancluslons r+epo�ted on this IoRn and thet they are <br /> cor►ect. <br /> Name: Joseph J.Olsun ,,,_ Certificatlon number: 1255 ,,,,__�„__ <br /> Buainess IicxnBs name and number; Rusty Olso�'s soil and per�culatlon testing Lic�810 or <br /> Name of local unit of govemment: Cfty of Orono _ <br /> Sign�ture: ,� Date_ 6/27/�9 <br /> wq-wwfsts�-31 Comp(lonce Inspection Form for Extscing SSTS <br />