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Parcel number: _ S,siem sta:us ❑ Compliant ❑Noncompiiani (as determined by this form) `��ra3� ��g��t� �r�d ��et� ��r��slia�� �€��ii�r:ee ;ss�p �2 ��s � Date of observation: Reason for observation: This form expires on (three years): Compiiance ques�iors/cri�te�ia: (Requfred) Verifzca�ior iVlethoa��: (Optional) (Check the a ro riate box) (Check fhe appropriate box) Does the system consist of a seepage pit', ❑Yes ❑ No cess ool, dr Nreli, or leachin pit7 ❑ Probed tank bottom i ❑ Observed lo�ni liquid level Do any sewage tank(s)leak be(ovv their I ❑Yes ❑No designed operating depth? ❑ Examined construction records Ifi yes,identify�t�hich seyvage ❑ Examined empty(pumped}tank tank leaks. ❑ Probed outside tank ior"black soil" Llny`yes"anst�e:i;r�'ica_es ii;at the s;si��,~t is�2%Il;ta zo.r,rotec� ❑ grou.nd w.ater. Pressurelvacuum check ❑ Other: ' Seepage pits meeting 7080.2550 may be compliant if allov:�ed in ordinance 6y local pennitting authority. `"No standard profoco!exists. This list is not exhaustive,in sequentia!order,not�does itindicate whrch combinatrons are necessary to make this defermination. Jdf2�� Ci']eC�C 1. �re an;�maintenance hole covers damaged,cracked.or appeared to be structuralh�unsound? ❑Yes" ❑iVo 2. Were all maintenance hole covers replaced in a secured manner(e.g.,aii screv:�s replaced)? ❑Yes ❑ No` 3. �.Nas secondary access restraint present(safety pan.second cover, or saiety netting)-highly recommended. ❑Yes ❑No 4. �fVas any otner safei;�;health issue present? ❑ Yes- ❑ No Exptain: =Sys±em is ar imrrrinent threat ta pu�lic;�ealth and safefy. ��i�3��ii�'!l This form is to be compieted and attached to the Summary Form of the Alinnesota Poiluiion Control Agency's(MPCA)Compiiance inspection Form ior Existing Subsurfiace Sewage Treatmen�Systems. Obsen�ations, interpretations,and concl�isions must be completed by an inspector, main�ainer, or ser�ice provider. Completed form must be submi�ied to the local uni"t of government�,vithin 15 da��s. Property ovdner name(s): " Property address: Property ov�mer's address(if different): --= — -- --- -- - -- ---- --- County: � Phone: r hereby certify that 1 personal(y made the observations, inierpretatrons, and concfusions repor�ed on ihis iorm and that they are correcr. Name: Certincation number: Business license name and number: or Name ot local unit of government: Signature: Date: wq-�nvists4-3i Comptiance lnspection Form forExis"ring SSTS =;1 i lOR