Laserfiche WebLink
05i25/2010 12:18 7634988290 RUSTYS PERC TESTING PAGE 05 <br /> . P����y�: _ _ System status: �Complie�nE ❑No�compliaM <br /> (as detem+ined by this fiorm) <br /> Tank tnt�g�ity and 8sfety Comp1[snc� <br /> Ee�B �ssu�#2-of 4 <br /> pate of observati�on: 5R1/10 Reason for obeelvatio�: _ProPertY Transt� <br /> �ftis fiv�tex�ine�cxt(�9e�): 5/2'�113 <br /> Compliance quesdonslcriterla:(Reaulrad) VarHication Mttl►od"': (Opuonel) <br /> Checic(he a riate box (ChecYc fhe apprapriate box) <br /> Dces t1�e system oonaiat of a seePage Pit', ❑Yea �No ❑ Probed tank bottnm <br /> cess I. II w leachin it? <br /> Do eny sewaQe tank(a)leek belvw thei� ❑YeS �No ❑ O�enred Iow Iiq�Id level <br /> desi ned ratk� de th? � F�aamined cAnstructlan�ecords <br /> If yes,identify which sewege � Examined empty(p�rtpad)t8nk <br /> tank leaks, p Probed outside tank tor w�adc soil' <br /> ,4ryr�yra"pnswvr indkatQs th�t tl�s s��a�to p�vesct � Pfese�A�E�ua�� <br /> gr�und wn+tsr. <br /> � Other Ende Se�t(c seryice----. _. <br /> ' Seepage pits meeting TOBU.2550 may be comp�lant lf allowed <br /> in or�nanbe tsy icscal�tmiHirtg atMortty. ---� <br /> "No sf&ndeld p/ptocd exist8. TT7is 1Jst is not exhaustive,in <br /> abQua�e!oide/ ►wi dbes�indlcete wlrich co+nbf»ate�ns <br /> ere�neceassrpto rsoakeN:iadete�ir+e&or�. <br /> Sa�fety Check <br /> 1. Ane anr main�enance bale�ouara�lamapa0.craciced.or�pnaired to�e atructurally unsaund� ❑Yes* �No <br /> 2. Were all malntenance hole cove�a raptsced in a sxured manner(e.g.,all acrews replaced}? �Yes ❑No' <br /> 3. Waa seoondary acoeea teetreint p�ese�+t(ssfety pan,second cover�or safety netting)—high�r recommes►tled. ❑Y88 �No <br /> 4. Was any other Batatyfheafth isaue pTeserrt? ❑Yes` �No <br /> E�lain; <br /> `Sysl�rn!�an lmminon!threat to pab/k i�a+lth ind safe!!Y. <br /> �ertifitaEicn <br /> This fomi is to ba oompleted and ettsched to tha Summary Fprm of the Mnnesota PoNution Control Agencr's(MPCA)Compllance <br /> ��spec�on Fonn for E�dsBn�$t�l�u�iaee Sevrage T�eabt5srit Sysbmt�.Obaervat�o7ts,irttYerpiatatlons,and conclus�ons must be <br /> c�le�d Et�/en ar�s�x,�eiflE�.�se►v6ee{x�er.�aaspleted fi�s�st be.submitted?a 1he local unit of govemmerrt within � <br /> 15 days. <br /> PrvpcKty otivner nae�fsy. Keilt+Fritse <br /> Proparty eddr�ss: , 2�15�cx,nCY�de Dr�ve Or�no MN 5535�6 <br /> PropeRy owner3 address(�f di9ie�r►t); <br /> Cou►ri�r: Hennepin Phone: 952�7&9�03 <br /> I hereby ceti/y tAat l personatly made the oDsenralior+s, interprefetiwrs, a»d tonCltrs�ons►epnifedon fhis fom►end fiiaf ffrey ere <br /> onnact. <br /> Name: JoS�bn J.DI3bn Certifiw�ti�arr rtamber= �t255r <br /> Businea I�se name arW number: Rushr Olsorf's sail entt paradelion�l:ic�814 or <br /> Neme of local unit mmenk City of Orono <br /> Signgtu[e. Daie: 5/25110 <br /> wq-ww[stsq.31 tompllcncc Inspection form for Existing SSTS <br /> 4/4/O� <br />