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.03/0 12011 17:52 7634988290 RUSTYS PERC TESTING PAGE 04 <br /> � <br /> F�a�el nu r. System steLis: ❑Compliant ❑Noncomphant <br /> i (as dete►mined Dy this forml <br /> �ank 1 teg y snd Safety Compl�an�e - Complienae Inspectron Fomr for Existi�g SSTS <br /> � <br /> ompli nceVssue#2 af 4 <br /> 4ate of o servetion: 3/1111 _ Reason for observatfon: Properly Transfer <br /> This fo�m Kpires on(three y ars): 3/1111 <br /> �omplisnce questans/c fia: (Required) Verifkatfon Melt�od": (optiona�) <br /> Check the e o 'ete x (Check Me eppropnate box) <br /> 4oes the system conslst of seapage pit', ❑Yes �No ❑ Probed tank bot6om <br /> ss ool dr ell�or leac�in it? _ „� <br /> ❑ Observed low liquid level <br /> 0 eny SeWage tank(s)leak eloW their ❑Yes �No <br /> desi ned o eretin de th9 ❑ Exsmi�ed conSVuction records <br /> If yes,identity which S Examined empty(pumped)=enk <br /> sewage hank leaks. ,_,��„ - - ❑ ProbeA cutside tank for"black soil' <br /> �r�y"y+ap'"anawer/n�aat� 8w eysten7/�f�ftlnp to proEYCI � pressurelvacuum check <br /> giound water. <br /> ❑ 01her. <br /> ` SeepaQe pits meeting�080.2550 mey be compli�nt if allowed <br /> in ordiner►ce by local permitting authority <br /> "No atandaid prvtoco!exiahs. Triis lisf is not axhauslive.in <br /> �qusrMal order, nor does iY ind�cafe which combinaGons <br /> ere necessary ro make lhis d8terminetron <br /> I�Safety Check <br /> I <br /> 1. Are maintsne�ce h01e cwers damaged,cracked,o�oppeared to be shuc�►'ally unSound? ❑Yes' �No <br /> 2. We�e ainbenance hole covers replaced in a secured manner(e,g.,scr�ws replaced)? �Yes ❑No' <br /> 3. Was ondary ecces+s restraint present(saFety psn,second caver,or saiety net�ng)—hiyhly recommended. ❑Yes N,�No <br /> I , <br /> 4. A�e er safety/heeltF�iseu�pteserrt? ❑Yes �No <br /> E �I <br /> 'Sysf�em la an qrpn �t tir►'est to pa61lc heald�and seAsiy- <br /> Certl�ication <br /> This b m is to be comple d�nd attached to the Summery Fo�m of the Minnesota PolluUon Control Agency's(MPCA)Compllance <br /> Ins�on Form tor ExlatlnQ Subsu►Tace sewage Treatmen[Sysbsma.Obse►vations, InterpretaUons, and concluslons must be <br /> compl ed by an inspector, malnfAiner,or service provider.Completed form must be submiRed to the local unit of gavernment within <br /> 75 de . <br /> Prope owner name(s): �►'�9h�PoB� <br /> Prope eddress: 2755 Deer Run Trdil Esst Orono. MN 55356 <br /> P�ope owners address(�fd�fFer�e.►t); <br /> County: Wennep�n Properry owner phone� 612-�47-0283 <br /> f hereby cerfify fhat I persone�ly msde the obae�v�tions,interpretefions. end co►�clusions repoRed on fhis fonn end thet they are <br /> correcr. <br /> Name; James 8raegelmenn Certfica6on number: <br /> 6usiness lice�se neme end number� Elmpr J_Pele►son Co. _Llcensei�219 _ ��_ or <br /> Name of loc nii of govemment; <br /> SignaRu�o: Date 3l1/1 y __..�.... <br /> www.pce.sts .mn.us • 651-296-6300 • B00•657-3664 • TTY 651-282•5332 or 800�65i-3864 • Available in al[erned�e formals <br /> eoo <br /> werwwts[s4-� • �/1A109 Poge 3 of 8 <br />