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Parcel number: 27-118-23-44-0008 System status: ❑ Compliant � Noncompliant <br /> (as determined by this form) <br /> Tank Integrity and Safety Compliance <br /> Compliance Issue #2 of 4 <br /> Date of observation: 6/10/9 Reason for observation: Real Estate Transaction <br /> This form expires on (three years): 6/12/9 <br /> Compliance questions/criteria: (Required) Verification Method**: (Optional) <br /> Check the a ro riate box (Check the appropriate box) <br /> Does the system consist of a seepage pit', ❑ Yes � No � Probed tank bottom <br /> cess ool,d ell,or leachin it? <br /> ❑ Observed low liquid level <br /> Do any sewage tank(s)leak below their ❑ Yes � No <br /> desi ned o eratin de th? ❑ Examined construction records <br /> If yes, identify which sewage � Examined empty(pumped)tank <br /> tank leaks. ❑ Probed outside tank for"black soil" <br /> Any"yes"answer indicates that the system is failing to protect <br /> ground water. ❑ Pressure/vacuum check <br /> ❑ Other: <br /> ' Seepage pits meeting 7080.2550 may be compliant if allowed <br /> in ordinance by local permitting authority. <br /> *"No sfandard protocol exists. This list is not exhaustive, in <br /> sequential order, nor does it indicate which combinations <br /> are necessary to make this determination. <br /> Safety Check <br /> 1. Are any maintenance hole covers damaged,cracked,or appeared to be structurally unsound? ❑ Yes" � No <br /> 2. Were all maintenance hole covers replaced in a secured manner(e.g.,all screws replaced)? � Yes ❑ No` <br /> 3. Was secondary access restraint present(safety pan,second cover,or safety netting)—highly recommended. ❑ Yes � No <br /> 4. Was any other safety/health issue present? ❑ Yes" � No <br /> Explain: <br /> *System is an imminent threat to public health and safety. <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 Subsurface Sewage Treatment Systems.Observations, interpretations, and conclusions must be <br /> completed by an inspector, maintainer, or service provider. Completed form must be submitted to the local unit of government within <br /> 15 days. <br /> Property owner name(s): LUCILLE M OFFERMAN TRUSTEE <br /> Property address: 1669 NORTH FARM RD LONG LAKE MN 55356 <br /> Property owner's address(if different): <br /> County: Hennepin Phone: <br /> 1 hereby certify that 1 personally made the observations, interpretations, and conclusions reported on this form and that they are <br /> correct. <br /> Name: Mark J Hayes Certification number: R5013 <br /> Business license name and number: Minnesota Geotechnical Services, LLC MPCA#L3203 or <br /> Name of local unit of government: Wright County <br /> Signature: M�/ ��� Date: 6/16/09 <br /> wq-wwists4-31 Compliance Inspection Form for Existing SSTS <br /> 4/4/08 <br />