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, . <br /> Parcel number. � �7 � �K . �'- �i System status: ompliant ❑ Noncompliant <br /> � � _ (as determine t�rs�f � . <br /> � ����.���#i�'�MC���.I.0 <br /> �:• , <br /> :€7���;3��i Py. N� <br /> Tar�k Integrity and Safety Compiiance . ��• ��ic�ael, iVI� S��76 <br /> _ Compiiance Issue#2 of�4 � ., <br /> Date ofobseroation: �- � �' �`� Reason forobservation_ �`l Y'Yl(a '� ��15 pc-' C� <br /> � " This form expires on(thr$e years}:- - oZ d �- � �, <br /> Compllance 4uestionslcr�teria: (Required) Verification aiAethod'*:�Optional) , <br /> Check the a ro riate box - (Check the appropriate box) � <br /> Does the system consist of aseepage pit*, ❑Yes �No � Probed tank bottorri ` <br /> cess ool d ei) or leachin it? � - <br /> Do any sewage tank(s) leak below their_ ❑Yes �(J No � Obsecved low liquid level . <br /> desi ned o eratin de th? � -Examined construction records . � - � <br /> (f yes, identify which sewage , � . � Examined empty(pumped)tank � <br /> tank leaks. � , � Probed ocitside tank for"black soil" � � <br /> Any"yes"answer indfcates that the system is faf/fng to proteci � . . <br /> ground water.- ❑ Pressure/vacuum check • . <br /> � . � ❑ Other. "`�-`/oo Q <br /> ' Seepage pits meeting 7080.2550 may be compliant if ailowed � -I`+—`-' <br /> in ordinance by_iocal permitting�authoriry. . , <br /> - � • � "No standard protocol exists. This list rs nof exhaustive,in ' - <br /> . . sequen�ial order, nor does it indicate which combinafions . <br /> are necessary to�make.this determination. � <br /> : .Safety Check � . � : � � : <br /> i. Are any mainfenance hole covers damaged,-cracked,or appeared to be structuratly unsound? �Yes* [�J'f� � � . <br /> - 2. Were al6maintenance hole covers replaced in a secured manner(e:g.;all screws replaced)? � �"�es ❑ No".� <br /> 3. Was secondary access restraint present(safety pan;second cover,flr safety netting)-highly recommended. ❑Yes [}Pfo ' <br /> 4: Was any other safety/health issue present? : � ❑Yes' [�to <br /> Exptaln: � � � � <br /> *System is an imminent thieat to publJc healtii and safefy. � <br /> Certification - <br /> This foim is to be completed and attached to the Summary Form of.the Minnesota Pollution Control Agency's (MPCH)-Compliance <br /> inspection Form for F�cisting SubsurFace Sewage�Treatme�tSystems.Obsen►ations;�interpretations, and conclusions tnust be.. . • <br /> completed_by an inspector,maintainer,or service provicier.Completed form must be submitted to the local unif.of govemment wifhin <br /> 15 days. - <br /> . � � � . <br /> Property owner name{s): C _ : <br /> Properry address: � - � . <br /> Property owne s add�ess (if different): � <br /> - County: Phone: � <br /> I _ _ <br /> !hereby certify that/personally made the observations, interpretations, and conclusions reported on this form and fhat they are � <br /> correct. <br /> Name: �' � Certification number: ��� �'' � `� <br /> Business license name and number: %�I i(a f'Ir�� �P�J{'1 L �'i"L'i Cf� L�^e- - f� 7��� or � <br /> Name of local unit-o�f�ovemmen� � . <br /> Signature: �=%u-�--._.� '��i-- =�u-�'�, � Date: _ % . <br /> _- --__ _ _ . <br /> wq-wwfsts�4-31� . . � Comptionce Inspection Form for F�cisting SSTS <br /> ei�inR � <br />