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lU/lU/'LUlL rrGU U8:1"L rAA bl'Ly4'LS1G4 llUUVLA� SLK��N YK1N7' l(/JUU4 <br /> . � ' <br /> ' ' Patc�l number. � � ' System status: Compllant ❑Noncompliant <br /> • (as dsfeimined by t�i Ua e�s SeptlC SeNiCe,U:C � . <br /> � 10502-31st Place N.E. � <br /> Tank�Intogrity and Satety Compliance • 3�Michaei,MN 55378 � - � <br /> . CompEiance Issue#2 of�4 �63-a9�-t7s4 ' . <br /> Oate of observ�tion: D ' 3 � '" � a' Reason for observatbn: <br /> ,' This form explres on(three years):� U � �i d � { � � <br /> Compliance questlonslcrite�ria: (Requtred) Veriflcation Method": (Optional) . <br /> Chedc the a rv date box � • (ChecJc the appropriate baz) � <br /> Does the syatem consist�of a�seepa9e pit', ❑Yes �No ��obed tank.bnttorti . � � � <br /> cess oo! d eU or leechin 'Y1 " � � � • <br /> . �bserved low llquid fevel _ <br /> Do any sewage�tank(s�leak bebw their. �Yes �No - � . <br /> des ned'o ralin tJe th? ❑ Examfned construct(on records � <br /> , H yes,iderdify which sewage ; . . Examined emPty(pumped)tank � . <br /> fank leak�. � � ' • . . <br /> . . • , Q'Probed outaide tank for"black sal' <br /> . My�ws'artswar/ndkatea Lhat the syst�m!s taping to pmtect � � . . - <br /> ws � - � <br /> �round�vetar. . . ❑ Pressure�vacuum check . <br /> ' Seepage pits meeting 7080.2530 mQy be campitant if alfowed � ��er �-� ,�"b . � ��,,�� <br /> In ordinance by.local permittlng�authority. .� . <br /> - � . "No�tandard protocol exiats..This tist ts,not exhausllve,!n - . <br /> . ' . � sequenda/wder,nor does!t Indkafe whtch combfist�ons ' <br /> � s�e necessary fo-►►�ake.this daterminatio». � <br /> : _Safety Check � � : � - . . . . <br /> � 1. .Are etiy maintenance hole covers damaged;�cracked,or appearod to be strudurally unsound� � �Yes• ' (�NO� ` . <br /> '2. We�e all-rnaintenance hole covers reptaced in a se�ured'marvser(e:g.;aIF screws re�laced}7 � . (�Yes ❑IVo'� <br /> 3. ' Was secondary access resttafntpreserrt(satetyr pan,second cover,or safety netti�g)—highty recommended. (�Yes � Q No <br /> . 4: Wae any other aefaty/health issue presenYl � . : � � . ❑Yes• �No . <br /> . . , <br /> Exp�ain: . :. . <br /> - •Sya;an l�an lmmin�nt thr�at Lo pubUc haa/thi andsafety.' � <br /> Certification � � . • . � -. <br /> - ;:< . <br /> fils��a�to be compkted and attached to the Summary Fatm oLthe Mlnnesota PcBution Controi Agency's(MPCA)-Compl�nce <br /> ' lpapeolfo�n�ofm for Exbttng Subsuriace Sewage-Twatment Systems.Obgenretions,�ir�teipcetations,and condusions must be <br /> compisted:bjl srt inapecfor;rnaintalner,or service provider.Completed form must be submittsd to the local unit of govemment wi{hin <br /> 15 days. . � - : <br /> _ . , . � , . . . <br /> Property owner name(s): � r . <br /> 7�-Property addreas: • <br /> �� ,Property owa rs address(tfditferent}: . . . ' <br /> _ , � <br /> � �ounry: Phone: � <br /> • . � . . , � <br /> ."I itere6y cedily lhat/peisonally made tho obseivatlons, interprelatia�s, and conc/usions ieported on th/s torm and that they are � <br /> corr�ct. � <br /> Name: �Q r?e� �� C��'lLI Certification number. C � G�� `� . . <br /> � L�� ���� �r . <br /> ' - 8usi�ess llcense name and number. 1�(�c�/1 P 5 �iP� �'l L `J�P t'V l e.• ______ � <br /> • . Nsme af local und ot vemment � . • � . <br /> ' � �-?�n i � . . <br /> Siana�ture: ' � �� � - . Dete: <br /> �.��.31 , , . Comptiance lrapecifon form for Existfng SSrS � <br /> .4/1/Oa • � � � <br />