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Parcel number: System status: �Compliant ❑Noncompliant (as determined by this form) Tank Integrity and Safety Compliartce - CompJiance Inspection Form for Existing SSTS Comp[iance issue #2 of 4 Date of observation: 10/15/12 Reason for observation: Point of Sale This form expires on(three years): 10/15/15 Compliance questions/criteria; (Required) Verification Mefhod**:(Optional} Check the a ro riate box (Check the appropriate box) Does the system consist of a seepage pit', ❑Yes ❑■ No � Probed tank bottom cess ooi,d ell, or leachin it? Do any sewage tank(s)leak below their ❑Yes �❑No ❑ �bserved low liquid level desi ned o eratin de th? ❑ Examined construction records If yes,identify which 0 Examined empty(pumped)tank sewage tank leaks. ❑ Probed outside tank for"black soil" Any"yes"answer indicates thaf the sysfem is failing to protect ground water. ❑ Pressure/vacuum check ❑ Other: " Seepage pits meeting 7080.2550 may be compliant if ailowed in ordinance by local permitting authority. '"'No sfandard protocol exists. This Iisf is nof exhaustive,in sequenfia!order,nor does it indicate which combinations are necessary fo make this determination. Safety Check 1. Are maintenance hole covers damaged,cracked,or appeared to be structurally unsound? ❑Yes* 0 No 2. Were maintenance hole covers replaced in a secured manner(e.g.,screws replaced)? [�]Yes ❑No" 3. Was secondary access restraint present(safety pan,second cover,or safety netting)—highly recommended. ❑Yes 0 No 4. Are ott�er safetylheafth issue present? ❑Yes" �No Explain: 'System is an imminent fhreat to pubiic health and safety. Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compliance Inspection Form for Existing Subsurface Sewage Treatment Systems. Observations, interpretations,and conclusions must be completed by an inspector, maintainer,or service provider.Compieted form must be submitted to the local unit of government within 15 days. Property owner name(s}: Johri Adams Property address: 4245 Chippewa Lane Long Lake, MN 55356 Property owner's address(ifdifferent): County: Hennepin Property owner phone: 952-473-9091 1 heretiy certify fhat!personally made the o6seivations,inferpretefions,and conciusions reported on(his forrrt�nd ihaf fhey are correct. Name: James Braegelmann Certification number: Business license name and number: Elmer J.Peterson Co. License#219 or Name of locai nit ofi govern nt: Signature: Date: 10l15/12 www.pca.state.mn.us • 651-296-6340 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats wq-wwists4-31 • 4124/Q9 Page 3 of 8