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Parcei number_ System status: (�Compiiant ❑Noncompfiant <br /> �as determine��r��so�m���=���=J�,Le � - . <br /> �v-3`E"i4�i:�i ir'i. ivti�. � <br /> Si. Michael, MN�5��6 : . <br /> Tank Integrity and Safety Gompliance . <br /> Comptiance Issue#2 of�4 � <br /> Date of obsecvation: �- o�1 Z Reason for observafian: S i II��^ <br /> This form expires on(three years):� � SS l S <br /> Compiiance c}uestions/crit�ria: (Required) Ver�cation Method'Y:�(Optional) . <br /> Check the a ro riate box (Che fhe appropriate b6x) <br /> Does the system consist of a-sespage pi#', ❑Yes No Probed tank bottorri <br /> cess ool d eil,or�leachin it? ❑ Observed iow Iiquid levei - <br /> Da any sewage iank(s)leak below their ❑Yes No � �amined construction records . � � <br /> desi ned o eratin de th? : <br /> [�F�camined empty(pumped)tank <br /> If yes,identify which sewage . . . <br /> tank leaks. � 0 Probed outside tank for"black soil' <br /> Any"yes"answer ind/cates that the syslem is failing fo proiect (] Pressurelvacuum check <br /> ground water. <br /> � ❑ Other. <br /> t Seepage pits meeting 7080.2550 may be compliant if altowed - <br /> in ordinance by local permitting�authoriry. � _ <br /> "'No standard protoco!exisfs. This list is not exhauslive,in� : <br /> � sequendal order, nor does it indicate which combinaBons _ <br /> are necessary to make.this determination. <br /> : Safety Check _ . <br /> 0Y s`. ' �NO� <br /> 1. Are any maintenance hole covers damaged,-cracked,or appeared to be structurally unsound3 _ <br /> 2. Were all•maintenance hole covers replaced in a secured manner(e:g.;all-screws reptaced)? <br /> y ❑No*_ <br /> 3. Was secondary access restraint present(safety Fan;second cover,or safety netting)—highly recommended_ Yes ❑No <br /> - ❑Yes' L�No <br /> 4. Was any other safety/health issue present7 � <br /> Explain: � - <br /> xSystem is an imminent threat to public heattfi and safety. <br /> Certification . � <br /> This form is to be completed and attached to the Summary Forrr►of.the Minnesata Pollution Confrol Agency's(MPCA)-Compltance <br /> lnspection Form for Extsting Subsurface Sewage�Treatment Systems.Observations,interpretations,and conctusions must be • <br /> completed by an inspector,maintainer,or service provider.Completed form must be submitted to the locat unit of gavemment within <br /> 15 days_ 1 . <br /> Property owner nams{s): - � <br /> Property address: L/ 0�� � �'Zc t�w�� d �� �� . • <br /> Property owne�s address(if d'rffarent): - <br /> County: Y�I N� <<�' --�-� Phone: <br /> !hereby cerfify that(pe�sonatly made fhe observations,interpretetions, and conclusions reported on fhis form antJ that theY are <br /> correct. � <br /> Certfication number. �� � �� �� . <br /> Name: J � �� � � C� i'' . t� . <br /> ` �T{-� _ �'t �' ,�, Li��' " IG -J Gl or <br /> Business license name and numbec _(�t i(��'I��� ' . <br /> Name of loca!un avemment: � �_r � • <br /> Date_ <br /> Signature: . � <br /> ..._ .._..:_._� �,� <br /> LomDtianc8lnsnectfan Form for Existin8 SSTS <br />