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�111161•2011 02:31 7634975011 SPTESTINGINC PAGE 07/09
<br /> uct�7'I'I U��:b/p Hlmar,l. I�Atw��on Go. 7G3��J72-7217 p,2
<br /> Par�el nurnber. System sta6us: f.�1 Compliant ❑Nancompliant
<br /> (es da�tc�nr�lpc�d by thls form)
<br /> Tank Mntegrity and Saiety �Cornptaar�Ce- Coh�pliance Ir�spection Form for�x�sfing SST:�
<br /> Campliance� iss�e#2 of 4
<br /> Date af abscroatlon; '�0/2A./11 Reason for obseruBCion: P��nt of Selp
<br /> Thfs f�orm expir�s ar1 (thrc�years); ip��4�14
<br /> Cornpliance questionslcriteria:(Requircd) Verification Method"";(Opdonal}
<br /> Check fhe ep�oroariAte box (Chech fhe sppro�ite boxl
<br /> �aes lhe system consist of s�segp�ge piY", ❑Yes [�■ No � prabed bnk bottorn
<br /> cesspool,�ell, or loaching plt?
<br /> Do eny�ew9ge tenk(s)leak below th�ir ❑YQs �Nn ❑ 06served low liquid levei
<br /> desfgned operati�g de�?,._ �__, ,_._. __ ❑ Examined canstruction reco�de
<br /> IPyes,identlry arhich 0 F�ts�mined empty(pumpad)tank
<br /> sev,rage t�nk leal�. ❑ Prabed ouzslde 1snk�For'I�lack soil"
<br /> Any"yes"sr�swer Indl�.�ics tl�at rho system is fe�lin�to pratPct
<br /> ,qro�nd water, ❑ Pressuralv9cuumchock
<br /> ❑ Other;
<br /> ' Seepage ptts rnecling 708D.2S50 may b�compilaht ifi allowed �"' �—'
<br /> in atdinance by local permit#irtg autharity. `._. _,
<br /> "No stena'Brd protocul exlsCs. This list Is noi�exhausNve,in
<br /> �BquenG91 o►der, nor daes Mlndfcakr whfch oombinaffana
<br /> mra necessary to rrFeke this da�Prm+nallor�.
<br /> Safety Ch�eck
<br /> 1, Aro melntanance hole covere dsrnaged,crecksd,or appeared��to bc struc0urally unsound? ❑Yas' �No
<br /> 2, Were m�intenance hole cover9 replecEd In a secursd manner(e.g„screws replaced)7 �Yes ❑No'
<br /> �, Was secondery s�cess restrAirrt presErrt(sal'ety pan,$econd cbvEr,or safety netting)--hiqhly recommen d�d. �]Yes }`J��]No
<br /> 4. /�re oUier,aferylhealth issu�pre�ent4 ❑Yes' �ij Na
<br /> Explainn �.... . --� ----- -
<br /> •Syscerrr Is an ir�rrminent fh►�rf to pu61Pc he�Jth and st�fery,
<br /> LertifiGation
<br /> Thls fann Is to he comp�eted and attached 2o the 3�imrrt�ry Form�oFthe MRnnesoia PalWtlon Control Agency's(MPCAj Compllapce
<br /> Inspectloq Form'f��xlstlng�Ubsurtace 5ewage Treatment�yslpms. Obsarvatians,i�erpretations,and cancluslans rnust be
<br /> completed by an Irtspector, mslr�alnQr,or servioe pr�vider,Campleted form rnust be submittedt�o the loc�l unit of ga�emment wlthln
<br /> 15 days,
<br /> Prapetty owner name(s): Dan and Kti�ti�e PetQ�s�n � ,,,.,;, _
<br /> Property address: .��g5 Cc�untrysldc Driv�W Long Lske.MN 55356
<br /> Property owner'S s�ddrEgS(if dlflerenl�: „ ,,,,,,_ .
<br /> County; Hennopin Prope�ty owrter phone: 952�76-0519 _ �
<br /> !hel�by certriy thAt I persoRelly►71ade(h�e obsetvatrori5, ittterpfefAfio»a, 9Pld concJusl�r►s reported on Ihfs�oA71 aRd thflt lhey aro
<br /> correcf,
<br /> Name; .lames BnegalMann , _ GertificsUon number,
<br /> F3usine�s Ilcense name and nu mber: E1mer J. PetArsan Co. Llcensa#219 or
<br /> Name oflocal of govemrnent; , �„ ,, _„_..
<br /> Sifl�ab.ire: � .���..,_—^`� Date; 1q19�4f11
<br /> www.pra.sCaCe.mn.us� � 631•286•630c? • 80U,657-36G4 • '7TY 651-7.6z•ry332�r B00•657•3864 • AYailab(e in altern�skiye torm�ts
<br /> wq-w►vrscse-si . el�iarog Pave 3 of8
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