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��'� �Mwv �a 20�3 10: 13aM No, '��696 �. � <br /> � r <br /> SkCtION 13:.Farms and Reference ■ �'�3.,�3 <br /> Y Pprasl 1lultebar Syslam 91atu�: ❑Cvmpllaflf [y n�pnppmp4arfl <br /> - (as dafennlned Dy►hls form) <br /> T'anK [ntegrtty and �atety Com�lfance=Cornpllence lnspectlen Form fnrQr;��inp SS73 � <br /> Compltan�e Is�u <br /> Ds�eqlobaervetlon; — Reasontorob�enretbn; <br /> This fa�m explres o»(ih <br /> Gompilanca quesU�ns/crltorla:(Raqulrad) , Ye�lftcatlon Mathod":(Opti�ona�) <br /> Check the �lere 50 � (Chack Iha eppropdate box) <br /> Daes�he syeiem coneisl of�aeAP9sB w+l'; ❑Yra �Na � 0 probed tenk bottom <br /> ceea ool d 011 0� aChin ll _ <br /> D�any saurage tanit(s}leak beloW[hslr []y�y �� ❑ Obsenred faw Itquld level <br /> deaf netl e et�6dn dtl A7 ❑ prBmined oonsVucUon recaNs <br /> If yea,idenfl(y which ■ Fxamin&d emplr(pUmped}tanK <br /> sawa9B lank leaks. [j pmb��y������k far`bl&Ck tnil" <br /> Any`yas�'•��tswo�/ndkatss ff�at u�ay6lan�Is filf/n�to prorae� <br /> graund w�lbr, 0 Pr�esyureMacuttm cl�eck <br /> ' Seepage plls meetng�Od0.25�0 may be cvmpliant IF allow� � d�e� <br /> 1n o►�In�m�ey tOcal perndttlnp authority. <br /> ' _ "NO lfend@Id pnofaep!eJd8G4.17i�s Hsf Is nof exhaUslive,In <br /> seGusMfel oMer,nardeea Rlrtdlcate wM�h cbmArnelfons � <br /> .are nacassery to,nsfn thls determinelbn. <br /> , Satety Cheek ' <br /> t_ qrg.malrttenaqCB hola ceuere damaged,crsckad,qr sppear�d to p$sfitdurally�p�7 �Yes• �No <br /> z Were malnbener+ee hnte Dovees reple0ed h►a 6aoo�ted mettrt9r(e.p.�'sC�ws replaCed)? �Yes ❑Np• <br /> � �was sarandery aocss�res�lnt presenc(satoly Wn�s�eoond wvar,or satety neltlln9)—�dgt�lY recommended, ❑Yas ' �No <br /> 4. Are other s�letylh��lth 169�l0 p�gsenl? , , , ❑Ye�• �No <br /> F�latn: <br /> '3ys�e,n la�n!mminant th�at ro pubtle he�lth and aNery. <br /> Cert�Hcati�n <br /> rAfs lorm iR ta pe wmpleted and��tached to Ihe Swrtmery Fdm o!tha Mk,��psola pallutlort Contro�pgarrcy's(Mp���mptlenee <br /> IrtqRaGllon�erm for ExleBng&ub�wfraa S�ivage Tnabnant Sy9teme,Obseniaxons,irne�re�atrona,��nd canCivalon9 muat he <br /> compl�ted by an InapQGo�melydalnar,er adrvlca prov�ds,Campleted tp�mu91 bs submlt�d to Ihe locaf unit of pevernment wllh�n <br /> 15 daya. � � <br /> ptaperiy own4r name(s): <br /> PrapeAy addr�sa: �i3,rt5 GQL.{tJ�,�'�5�, _ pQ��.",� ' <br /> ��,— ��t�._._,—. , <br /> Properly awner'��ddress(ud�RBranl�: ����� <br /> Go�mty: rj • <br /> P�PBnY�1ar phane; <br /> !her�by cerflly that f�rerspnafly mad�fb9 oba6rvaliorl�fnfe�p►9(eflW►e,snd aanefuslona�po,ted an!h!s form-nnd fhe�Ihey�re <br /> correct <br /> 1 - <br /> N811�e: Iv� �� � 6`�'�. carihloollon Vmher: <br /> .. susiness ucensa qame�n0 numtrer: ��' ��,�� � ��" <br /> - a <br /> , Name of loc t o I '�tunent; . <br /> S1g�dtUfH: da19: �' '� <br /> !'�!� ���Ga9� �ON 6b1•296•6300 • BODb57•]d61 . 17Y651•2bz-.5332aau0-657-)eW • �a�}���i�����Z E� '�p{11� <br />