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05/ � 14:26 9528733112 PAGE 03169 <br /> Parcel number __ �_� ,� System status: �Compllant Q Noncompliant <br /> (as determined��is form) <br /> Tank Integrity and Safety Compliance <br /> Compliance Issue #2 of 4 ' <br /> Date of observation: ^�>��(�� Reason for observation: . — <br /> This form expires vn (three years): <br /> Compliance questions/criteria: (Required) Verification Method"": (Uptionaf} <br /> _ (Check the ap,propriate box) (Cheek the appropriate box) <br /> Does the system consist of a seepage pit', ❑Yes �No Q probed tank bottom <br /> cesspool,drywell, or leaching it? <br /> Do any sewage tank(s)leak below their ❑Yes �No ❑ Observed low liquid level <br /> desi ned o eraCln de th? ❑ Examined construdlon records <br /> If yes, Identify which sewage �Examined empty(pumped)ta�k <br /> tank leaks. <br /> ❑ Probed outside tank for"black soil" <br /> Any"yes"a�swer!ndlcates that the system/s fa!ling to protecf <br /> ground water. • ❑ Pressure/vacuum check <br /> (] Other: <br /> ' Seepage plts meeting�080,2550 may be cvmpliant if allowed �� <br /> in ordinance by local permitting authority. <br /> "No standard protocol erists. This list ls not exhaustive, in <br /> sequential order, nordoes if indicafe which cambinations <br /> are necessary fo make�hrs determination. <br /> Safety Check <br /> 1. Are any mainlenance hole covers damaged,tracked,ar appeared�o be struclurally unsound� ❑ Ye5' �No <br /> 2. wore atl maintenance hole covers replaced In a secured manner(e,g„ all screws repla�ed)? �,Yes ❑ No' <br /> 3, Was secondary access restraint present(safety pan,second cover, or safgty netting)-highly recommended. ❑ Yes �No <br /> 4, Was any ather safety/health issue present? ❑ Yes' �No <br /> Explain; <br /> •Systpm is an Imminent thr�eat to pu6Jlc health and sefety_ <br /> Certification <br /> This form is to be completed and atteched to the Summary Form of the Minnesuta Pollution Control Agency's (MPCA) Compllance <br /> Inspectlon Fortn for Existing subsurtace Sewage Treatment 3ystems.Observations,interpretations,and conclusions must be <br /> completcd by an inspector,maintainer,vr servlce provider.Completed fonn must be submitted to the local unit of go�ernment within <br /> 75 days. <br /> Property owner name(s): J <br /> Property address: � _ _ 1"1� l'1 �.. _�.------- .._. ---_. <br /> Property owner' address (li d�fferent): <br /> �...�_....------ - <br /> COunty: ��, � _ PhOn@: _..._�_ _„ ,. ----. . <br /> l hereby certify that I personalfy made the observat�ons, interpretetions,and conclusions reported on this form and that they are <br /> correct. ' <br /> Name: �(�� �a�`l�� _, Certification number. �p5�_� <br /> 9usiness Ilcense name and number: _ \ 'C� .�„___. _ or <br /> Name o(local unit o ern , � <br /> Signature: _ � _ Date: J/ _�.._ ..----�-_ <br /> `--7 <br /> wq•wwisrs4-31 Compliance Inspecrion Form�o�Existing SSTS <br /> 4/1/OE1 <br />