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Apr 22 1012:OOp 763-213-0695 p,4 <br /> . � <br /> Parcel number: �77� ��°'"�' �r�l S�� .�r� lN�Sf �2o''�Ystem status: �Compliant ❑Noncompliant <br /> (as determined by this fcrm} <br /> Tank integrity and Safety Compliance <br /> Compliance Issue #Z of 4 , . <br /> Date o(observation: �l-� 1- �U Reason for observation: _ � <br /> This form expires on (three years): <br /> Compliance questionslcriteria: (Requ�ired) Verification Method**: (Optional) <br /> Check fhe a prooriate box (Check the appropnate box) <br /> Does the system cor�sist o(a seepage pit`, ❑Yes (� No ❑ Probed tank boltom <br /> cesspool, drywell. or leachin it? <br /> � Observed low liquid level <br /> Do any sewage tank(s}leak below their ❑Yes [�No Examined construclion records <br /> desi ned o eratin de th? � <br /> If yes, ideniify which sewage � Examined empty(pumped)tanlc <br /> tanfc leaks. ❑ Probed outside iank for"b!ack soil" <br /> Any"yes"answerindicates that the system)s faifing to proiect � Pressure/vacuum check <br /> ground water. <br /> ❑ Other: <br /> ` Seepage pits meeting 70802550 may be compliant if aUowec <br /> in ordinance by local permitting authority. <br /> "No siandard p�v�oco/exists. This list is not exhausGve, m <br /> sequeniia!order, nor does it indicate which combinati�ns <br /> are necessary to make lnis determina�lOf1. <br /> Safefiy Check <br /> 1. Are any maintenance hole covers damaged,crackec, or appeared to be structurally unsound? ❑Yes' � No <br /> 2. Were alk maintenance hole covers rep€aced in a secured rnanner(e.g., all screws replacedj? �Yes ❑ No' <br /> 3. 'Nas secondary access �estraint present(safely pan, secon� cove�,or saFety net'ing)-highly recommended. ❑ Yes � No <br /> 4. 'Nas any other safety/healtt�issue preseni? ❑ Yes' �f No <br /> Expfain: <br /> "System is an imminent threat to public health and sa/efy. <br /> Certification � <br /> This form is to be cornpleted and attached to the Summary Form of the Minnesota Pollutian Control Agency's(A4PCA) Compliance <br /> Inspection Form for Existing 5ubsurFace Sewage Treatment Systems.Observations, inlerpretations,and conclusions must be <br /> oompleted by an inspector, mainlainer,or service provider. Completed form must be submitted to t3ie loca{unit ef governmeni within <br /> '15 days. <br /> PropeKy ov✓ner name(s): ___�[i1���r ' �w -� - <br /> Property address: _ 02 7 7S LU�i 5� �� �e �' <br /> Property owner's address(if dif`erent)= �n- k«��� • ---- <br /> County: __ �F�rw�; Phone: --y�- G� �Q L 0 3 �.5�-33�� 3� <br /> !hereby certify that I personally made the obsen,�ations, rnterprefations, and conclusions reported on ihis fvrm and thaf fhey are <br /> correct. <br /> Name: __ ��/1._ .� __ Certification number _ a� ���-•—. --._----. <br /> Business license name and number. .�= ,/v0�1�� �.2 5 C-D� l�✓z- � 3'�3 . ______ or <br /> Name o€loca� unit of government: ___ __ _ <br /> Signature: ___ .__ _ --• Date; -.--� !"�� _--- <br /> wq-wwists4-31 Compliance Inspection Form jor Existing SSTS <br />