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•.•.. � � �.. �...viu �niiv� u.rciviav�i v�. In3-y1L-/L I / p.L <br /> i <br /> Parcel number. System status_ �Compiiant ❑iJoncompliant <br /> (as determined by fhis form) <br /> Tank Integ�#y and Safety Compliance - Campliance lnspectron Form for Fxisting SSTS <br /> Camp(iance issue #2 of 4 <br /> Oate of observation: �Q��30 Reason for abservaaan: Reques!From tiomeowner <br /> This forrn expires on{three years): 1018110 <br /> Compliance questionslcriteria: (RequiredJ Verification Method**:{Op�onal) <br /> (Ci�eck the appraprrate box <br /> (Check the appropriete boxi <br /> Joes the systerr�consist of a seepsge pif', ❑Yes �Na � prabed tark boYom <br /> c oi,d e{I or ieschEn 't? <br /> � ❑ Observed iow iiquid level <br /> Do any sewage tank(sj?eak below their � ❑Yes � No <br /> designed oeerating depth? ! ❑ Examined construction records <br /> If yes, iden6fy which [�] Examined empty(pumped)tanR <br /> sewage�nk leaks. ❑ Probed autside tsnk for"black soil' <br /> An�"yes„answer lnd�cates ihet ihe system is talling ro protaet <br /> grottod water. ❑ Pressuralvacuum chedc <br /> ' See a e ❑ Q1her � <br /> p g pits mee�ng 708Q2550 may be comot;ant if allflwed <br /> !n flrdinance by iocal permi�ing authority. <br /> "'No standa►d proteco!exists. This list Is rrot exhauscive. in <br /> seqwential order.nor dces if ir,oticafe�ch oambinabons <br /> are necesssry to rnaks t�iis detertninefion. <br /> Safety Check <br /> 1. • Are maintenancs;�ole caYers damaged,crack,ed, a appeared to be structt:rally c:nsaund? ❑Yes` �No <br /> 2. L'Lere mair�tenance hate covsrs replaced in a secured man�er(e.g.,scxsws replaced)? Q Yes �1Vo` <br /> ?. Was sscondary access restraint present(safety pan,sscond cover,or safety neriing)—highly reco�nm�ded. ❑Yes� No <br /> d. A�2 ath�r saf�tylFtealih iss�ue prsserzt? ❑Yes" �Na <br /> Explein: <br /> 'Sysiem/s an immirtet+t thr+�az in publlc hea�lth artd safefy. <br /> Certification <br /> This form is to be cornplated and aitached to the Surnmary s=ar►n ot ths Minnesota PelE�tion Contral Rgency's(WiPCA)Compltance <br /> Inspectlon Form for Existiny Subsurtace Sev,rage Treatrnerrt�ystems.Observatiores, interpretations, and conGusions must be <br /> completed by an inspector, mainta�ner,or service provider.Completed form must be submitted to tl�e loca{;.init of govemmen,v+rithirt <br /> 15 days. <br /> Properry owr,er name(s): Chris Smith <br /> Propecty address: 2943 Fan�iew l.ane Long Lake. MN 55356 <br /> Prgperty owne�s address(ildiBerent): <br /> County- Nenriepin Praperty ownar phone: 952-9�3-7588 <br /> l neieby�erfify Lhat 1 personafiy mada fFie abservations,inteqoretetiorrs,artd conctusions�poRed on ffiis form and ttist they are <br /> correct. <br /> Narne_ .:am�s Braegeimann Certificxtion number: <br /> �usinass I:censs name and number. E�mer J. Peterson Co. License#218 or <br /> Name of locat�nit of govemme . <br /> Signahxe: �� D�e: 1018a'10 <br /> www.pca.state.mn.us • b51-296-6300 • 8�-657-386A • TTY b51-282-5332 or 800-b57-3isb� • Availabte in alternative formats <br /> wG-wwlsts4-31 . 4I24I04 �age 3 of 8 <br />