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09/16I2616 10:16 7634988296 RUSTVS PERC TESTING PAGE 04 <br /> _�r . . .� .. ..• .r. �....... ��. ................. �v.,-.i��-r��i N.c <br /> Darcel number �Rem atatus: ❑Compliamt ❑Nonco�ltar�t <br /> (es estermined by thla fbtrrtl <br /> Tsak Intopr�ty ��d Ss��ty Cornplla�ce - Compliance lnspecffon Form for Existing SSTS <br /> Cornp�ance I�sue #2 oF 4 <br /> Odb of�rvatfon: 9/14l10 Rsason 1or of�erva�n: �Gueat b�m Nnmeawner <br /> This f�rn sxpirss an(t�res lr�sr�)- 9I44/10 <br /> Compliwnce quQstbnslp'16ae1�: (R�qulrod) V�riflciljo�t M�fiod":(G�onal) <br /> Check ths -ats (Chec�r fhe sp,propasts box) <br /> Does�e syatem r�►�siet af�se�ade piC, []Yes �No � Probsd tarfk�ottom <br /> xas ocl d ell or I achin <br /> ❑ Observrd law liquid kvN <br /> pa any s*w�p tfnk(s)Ioak Eelow their ❑Yes �No <br /> de�gn.d opar�tinD de�� ❑ Examined construction recorda <br /> if yc�,idenU�y whioh � Exam�ned�fi/iP�mP�dJ cank <br /> sewage hnk leaka. Q Probed oLffiids osnk for'�blacK�of!�' <br /> ,4ny'yea"i►�r�'lndlost�s edat A�sy�tesr is lidNay to prr�ci p Pre�ut�elvacuum check <br /> pround�r. <br /> ❑ Oiher. <br /> ' Seepsp�pNs moef�9 70�.28�may be comp�snt f(dlowad <br /> in ordinen�by Ixsl pemut�n�aud�orlty. <br /> "No�i�OtM Prolowl eY�. Tlria liat ls nof�xha�Nur.in <br /> y�qu�tisJ o�ir,nor Qoe�li indica(m whloh corabFn6f(onw <br /> �r�tisosestry Eo make Ehia dafe�tnTn�6'on. <br /> 58f8'�G'IHCMC <br /> 1. Are maln�ensnoo hole coar�t d�rrsaQed,c»claed,or appeared b ba struc�uralip unsoucd? ❑Yes' �Alo <br /> 2 lhlere melnber►ance hole�ovsrs ropia�xd irt e seaaed mrmer(e.p.,sva�n�s replocsd)? �Yes ❑No` <br /> 3. H/es meoandary aooe�s re��i�rtp�esor�t(s�lf9hr Ra���^d cover.a►ash�tyY nq�8r�—hignhr roca�mend�d. ❑Y���No <br /> a_ are aiher saietvm�s i�uo P'r�m7 =]Ye6• �Wo <br /> 6�lain: " <br /> �Sy�tan Is an(mmlrw►n dtn�to puMlc hNff��nd safiey. <br /> Cerdffcetion <br /> Tfti�finn fs eo be c:omPlmt�d�nd�tschad to Ote Stemm�y Form of th.Marmetota Pollution Cortrd A9■ncy'e(M PCA)Compllance <br /> Inspootlon Form 1bt Ex1�n0 Sabsurmae Swvap�Tre�tm�nt S�slenw.Obaervetlans,Ir�t�erpret�tions�gnd ccnchasions must be <br /> camplat�ed bq an inmpedor, nwir�alner,or sqrvice prrn►i�sr.CcmpfsEsd tbrm�ba��mit�ed ho the locm unit of S+ovsrnm�nt within <br /> 1 S days. <br /> propeny aymar rtame(s); Carl6on H be <br /> Property ad�9ree�: 3483 GhNs�na O�e MePie P1�in.MN SS359 <br /> Property owr�6 aAd�(a�rent� <br /> :.Ovrrty_ l�n�� FioV�tY ovme�{�+a��_ $1238P$116 <br /> f he+�by csrtifY ihet I peraonalty rnade 1Fie observab+o�ini�+tioil►B.�oondUsfona roporced on this Ibrm�►1d cP+et lhoy are <br /> ��. <br /> Nams: Jamee B+'a msm Certlfir.atlon rwrnbe� <br /> 6u�ine�6cena�name and n�mder: Elmer�-P�ete�x►co• Ucens�218 or <br /> Nsme of I it oT gov <br /> ����. p�: 9V'I4f10 <br /> www.pCa.stah.mn.u9 651-1�6-6�0 • 80o-6S7-3d6� • TTY 651-18�2-l33Z or 800-6�7-36ba � Aveiteble ih elGernatfve lormetc <br /> ,.,�,....�.�.?te . uat�o9 Aage 3 0l8 <br />