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Parcel number: 3311823430017 System status: � Compllant ❑Noncompllant <br /> (es determined by th/s 1�rm) <br /> Tank Integrl#y and Safety Complianco <br /> Compliance Issue #2 of 4 <br /> Date of observation: S/24/10 Reason for obaervation: Property Transfer <br /> 7his form expires on(thtee yeers): 5/24/13 <br /> Compllance questlons/ctiteria: (Required) Verlflcatlon Method'": (Optionel) <br /> Check the a rn Nete barx (Check the appropriate box) <br /> Does the system consist ot a seepege pit', ❑Yes � No Q Probed tank boriom <br /> cesspool,drywell,or leaChin It? <br /> Do any sewage tank(e)leak below their ❑Yes � No ❑ Observed low liquid level <br /> desi ned o ratln de th? � Examined construdion records <br /> If yes, Idenlify which sewage � �xamined empty(pumped)tsnk <br /> tank leaks. [] Probed outsid�tank for"black soll" <br /> Any"yt►s"�nswar/ndkatea ehat tha system is falllrrg to pivtect <br /> g�vund water. ❑ PressureNacuum check <br /> ❑ Other� Pelerso�CompanY <br /> " Seepage pits meeting 7080.2550 ms�y be complient if allowed <br /> in ordinance by local permitting authorlty. <br /> "No afendard pmtocol exisfs. This list is not axhausti�re,in <br /> sequenHel ader, na doea!t irtdicate which combinationa <br /> ara necessary to meke thls daterminatlon. <br /> Safety Check <br /> 1, Are any maintenance hole covers demeged,cradced,or appeared to be alructurelly unsound? ❑Yes" � No <br /> 2, Were all maintenance hole covers replaced in a Secured manner(e.g.,all sc'.rews repleced)? �Yes ❑ No" <br /> 3. Wes seoondary accoea reatraint present(saFety pen,second cover,or ssloety netting)-hlghly rocommended. ❑Yes � No <br /> 4. Wea any othe�safety/hea0th issue preaent? ❑Yes' � No <br /> F�cplain: �....._._..�_..._........ <br /> •Syitom fs an Imminsnt tl►r+e�t to publlc hw/df►art0 aahty. <br /> Certification <br /> This fn�m is to be oompleted and attached to the Summary Form oi the Minnesota Pollution Corrtrol Agency's(MPCA)Compllance <br /> (nspection Form tor Exlstlng Subaurface Sa�ge Treatrnent 8ysbama. Observations,interpretatfons, and conclusfons must be <br /> completed by an inspector,mainfsiner,or service provider.Completed form must be submitted to the local unit of govemment within <br /> 15 d�ye. <br /> Propertp owner name(s): Kenneth 7:agzebski , <br /> Property addreas; 2700 CoapeNi�,nr Drlve Orono,MN 55356 _ ___- <br /> Property owners address(if difFerent): ,,, <br /> CouMy: Hennepin Phona: 61Z-20�8473 <br /> 1 hereby certify that I persona/fy made the obseivedana, lnterpietetions, and condusia�+s reporhgd on thls Iform end that they aie <br /> conect. <br /> N�me: Jose h J.Olson Cert'�fication number: 1258 . <br /> Business I'ioer►se rtame and number: Rushr Ol�on's soil and peroculation teelirtg Lic�810 p� <br /> Name of local unit f mmeM: Cii r of Orono <br /> Slpneture: Date: 5/25/10 <br /> wq-wwlsts4-31 Compliance Inspection Form for Exlsting SSTS <br /> 4/,/OB <br /> b0 �Jdd JNIlS31 ��13d Sh1Sf1�1 06Z886b�9L 9b�0Z BTBz/5Z/50 <br />