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101161200a 20: 42 9527586278 ADUANCED ONSITE INC PAGE 65
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<br /> Parcel numbe�: ,w.,, ,�__� uy ,�, _____ 5ystem siatus: �Complfant ❑Noncompliant �
<br /> (as defermined ,v this form��
<br /> 'Tank Integrity and Safety Complianc�e
<br /> �:ompliance Issu�e #2 of 4 �
<br /> uate of observation: ���%�_ Reason tor observation: �v �l � � ' .
<br /> "�'his forrn expires on (three years): ___�Q_��p`� M��.M -I6�
<br /> Complianca questions/c�iteria: (Requir+ed) VerifiCation Method�*: (Optional)
<br /> (Check the a ro riate box �'
<br /> —���--��-•---•- (Cher.k thp a�pm�nAtp h.nx) �
<br /> Does the system consist of a seepage pit', Q Yes No !
<br /> �Probed tank bottom� �I�
<br /> r,essEool,drywell,or leaching pit?____, � .
<br /> � ❑ Ob�crvod low Ilquid lev' I
<br /> Oo eny sewage tank(s) leak bclow their ❑Yes �No ' +
<br /> desianed o e�ating depth� W ❑ Examined construction records j
<br /> �f yes, iclentify wFiich sewage • ❑ Exa�nine� einply(pumped)tank �
<br /> lank leaks. � ❑ Probed oukside tank for"black soil" ' '
<br /> Any"yes"answer indlcates that ehe system is failing to prorect
<br /> ground waber, � ❑ Pr'essurelvacuum ChECK '
<br /> „ , � Other��I���, ��rs �6„��r'/�
<br /> 5eepage pits meeting 7080.255D maV be compliant if eliow�ed
<br /> in ordinance by local permitting autharily, 1� /�C ldi���
<br /> *"No s[endarc�protocol exlsts. Thrs lisi is not exhausfive,�!n �
<br /> sequen(IaJ orcler,nor does i!lndicete which combb�ali� i�� �
<br /> are necessary to make thts doterminaUon,
<br /> �afety Check , � �
<br /> �. Are ariy maintenan�o holv covers damaged, cracked, or ap�eared to be structurally unsound? [j Yes" .Jo �
<br /> :� Warp all mafnten�nCe hole coverc raplaCod in a seoured m�nne�(C:g.;all 3cr�ws replaced)? �Yes ❑ ilU"
<br /> 3. Was secandary access restraint present(safety pan,second cover, or safety netting)-high{y recommended. ❑Yes lo
<br /> 4: Wae 3ny othe►'eafcty/hcolth iaouc pro3ent? •
<br /> ❑Yes" � �o
<br /> Explain;
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<br /> 'System is an lmmPnen[tl��b�,�(u Nul�lic health and safery. �
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<br /> �crtifi�ation _ �
<br /> 7his fo�m is to bE completed and attached to the Summ�ry Furm of the Minnesota Pollution Control,4gency's (MPCA)Complia 1�;e
<br /> InSpeCtion �orm for Exiseting SubsurFaee Sew�ga Troatm�nt Syeteme.Obcervotiona, intcrpretations, and conclusions musY �;e
<br /> completed by an inspe�tor, maintainer,or service provider. C�mple4ed form must be submilled to the locel unit of goverllment w hin
<br /> 15 days. .
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<br /> Properry owner name(s); _���,,�Ty,�� , �_
<br /> Property address: �,��,���I/I v.ui�,__L rn �� �, �53��.�
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<br /> Property owner's ad ress (i1 dii�erenty; W . ,
<br /> Counry� �_ �, I'hone: —_��� J
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<br /> 1 hereby certify thaf I personaNy made the observetions, Inter��retafions, ar�d conclusions rvported on this form�a�t!that they are I��
<br /> correci.
<br /> �Jame: --��JJ_C�!.f.�_—���._� �., c��.�f�pt�e� numb�r.
<br /> �usmess Iicense name and ber: __��/�/r�,G��_���'�r `_�/_��� �
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<br /> tJame of Iocal unit ofy nt: _ ��
<br /> Signature: ` _ , Dat�: J��
<br /> �_,._,..�.�...
<br /> wq-wwictc4•31 f'!
<br /> Complfance Inspection Furm jor ExisCing 5�9T5
<br /> �r/1108 . (I
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