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07/18f2011 1?:32 7634988296 RUSTVS PERC TESTING PAGE 04
<br /> Parcel number 3311823.'�.�0003 _ ,,,_ System stetus: � Complient ❑NoncompliaM
<br /> �., (as determJned by this fnm►)
<br /> Tank I�tvg�lt�l and Sa1�et�l Cwnpllance
<br /> Compliante Issue #2 of 4
<br /> Date of observetion: 7/13/11 Reason for obeervetion: PropertY Transfer _ „
<br /> This form expi�es on(three years): �7/13/2014 . .. .. ,
<br /> Compliance questions/critetia: (Required) VoiiNcation Meti�od"': (optionat)
<br /> (Check the epp►opnaDe box) _ __ .�„, (Check the appropriate boxJ
<br /> Does the system consist of a seepage pit•, ❑Yes I� No ❑ probed tank bottom
<br /> ceaspool,drywell,_or leac�ing pit? __
<br /> ❑ Obsenred low liquid level
<br /> Do eny sewage tank(s)leak below their ❑Yes � Nv
<br /> designed operating.de�th7 _ � Examined oo�structio� records
<br /> If yes, idenHfy which sewage ❑ Examined empty(pumped)tank
<br /> ta�k leaks. ,,,_ ❑ probed outside tank Tor'bladc soil"
<br /> Any"�s"answ�ar lndkabas pwt the spsl�m is faNMg ba proiaet ❑ Pressure/vacuum chedc
<br /> �und w�i�►:
<br /> ❑ Other: , _ .
<br /> ' Seepeg�pks m�eting 7080.2550 mey be complient if allowed
<br /> in prdinance by local peRnitting euthorlty_ • �- —
<br /> "No stendeid p�otocnl exists. This list is rrot exhaustive,in
<br /> aequential o►der,rwr does it indicefe whrch camDinaHons
<br /> are necessery b make thls determination.
<br /> Safety Check
<br /> 1. Are any mainbenanoe hole covere damaged,cradced.or eppesred to be gtructurelly unsound? ❑Yes' �No
<br /> 2. Were all maiMe�anoe hole ooveis replaood in a seared manner(e.g.,all saews replaood)7 �Yes ❑ No'
<br /> 3, Was s�ec;ondary�ooess restraint prese�t(safety pan,seoond cover,or safe�ty netting)–highly recommended. []Yes � No
<br /> 4. Was eny other saFety/heslth issue present7 ❑Yes" �No
<br /> Explain: _._. .. �_ __ . --
<br /> 'Syat�m is an/mminent thnst to publlc heal�and aafety.
<br /> CertifitatiOn
<br /> This fortn is bo be completed and attached to the Summary For►n of the Minnesota PoNution Conirol Agency's(MPCA)Compliance
<br /> Inspecdon Fortn for Existing SubwrFace 8erra�e Trvafi�eM 8ystems.Observatbns,mterpretationa,and condusions must be
<br /> oompleted by an inspecter,mai�taine�,or servloe provider.Completed fomi must be submitted to the local unfl of govemment within
<br /> 15 days.
<br /> Property owner name(s): Dou9las Reynolds .�,,, „ _ ._
<br /> Property address: 75 Crystel Creek Road,Orono�MN 55356 ,,,.
<br /> Property owners addnees(iF diNereM): ,_ ,....
<br /> County: Hennepin_ ,_. Phone: 612-325-2570 ,. ,,�
<br /> 1 heieby certily that 1 personelty mede the obse►vations,In(�iprete6or►s, and aa�clusla►a reported on thls form and that they e�
<br /> conect
<br /> Name: Joseph J.Olson .,� m w__, Certfflcation number_ 1255 �, _
<br /> Business license name and number: �Rusty Olson's soil and�ernuletion Lesdng Lic�810 , _ _ ,,,� or
<br /> Name of local unit of emment: City of Orono ,_ .
<br /> Signature: _n � - _,,,,__ Date: 7/15/11 �.�,_ .
<br /> wd_Nny�s�sq_j� Compl�ance lnspection Form for Exlsting SSTS
<br />
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