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111e2/2010 21: 25 7634975011 SPTESTINGINC PAGE 05109 <br /> �oN � � �vv._,c i� r_tR1erJ. Netor��n Cn 7G3�972-721� <br /> p,2 <br /> harcel numb�r: � �� System sratus; �co 16ant <br /> mp 0 Noncompliant <br /> (as determinerJ byrhls Ibrm) <br /> Tank I�ntegrity and S�f�ty CompM�ancQ --Comp,lran�e lnspsction Forrn ior Exis�ing SSTS <br /> Camplian�ce Issue ,#2 of 4 <br /> Date nP obsenraHon; _9f15/16 Reasort fOr ahs�rvaUon: f�equest fn�m Homcawner <br /> Thls form expires on(thre�yaars): gl15l10 ' " � <br /> Cornpliflnce quesi�ons/crii,eria: (Required} Ver�fZcatian Methoq"*�(Optlonal) <br /> (Check tJ7e epproprr�bQx Check the a <br /> ( ppropr�a,n;box) <br /> Does the system consist of a seepage piY', ❑Yes [■j No <br /> cesspool, drywoll, or leachln� it? ❑ P�obod t�ank bottam <br /> Do any sewag�i�nk(s)Icak below'thsir ❑YQS �No ❑ Obse�rved Idw Ifqufd level <br /> desi ned o eratin d h? ❑ Examined c�onstructlon record� <br /> If yes, Identilyl which �■ Examined cmpty(pump�ed)tonk <br /> sewqge tank leaks, <br /> ,�ny"yes"onswerindicaEes drat�ha ❑ Probed outslde t�nk For'black�il" <br /> sysrem,fs�IAn9�prot� <br /> ArvunrJ watpr. ❑ Pressure/vacuum check <br /> ' Seepage pits mee�ting 706d,�55fl mey be cornpllant if allowed � ��or; <br /> Irt orcklnence by Inral perml�ittg authority, <br /> "No stqndard praMr,Qlexh.�ts. Thi�slisfisnofexhc�rrflve,in` <br /> sequentia/order,nor does i!lnd(c,pte w1�lch combinafians <br /> ar�rnacessary to ms►kR thls det'�nnJnatian. <br /> Satety Check <br /> 1. A►�e malrrtenancE hale covers damaS�ed,craCked, or appeAred tr�be struclu��lfy unsound7 ❑Yes" �No <br /> 2, Were melntanance hole covars repleced In a�acured manner(e.g_,scr�wa rep�aced)� �Yes �]No• <br /> 3, 4'Vas secondary access rostraint pregent tsaFety pan,s�cond cover, or s�fety netiing�–highly recammended. ❑yrs� Id'I�� <br /> �1, Aro o13�a,r safeiy�health isaie presenL? �Y� <br /> Explai�; ❑��3� �No <br /> �sysrem is an!mm!l�nt thnear za publlc I�Qaf�h and s�fe.ry. <br /> Cert�f�cat�or� <br /> This Porm is to be complc4�d and s�ttached ta{11e St�mmary Form of the Minnesata Pollutio-n Carrir�l Agency's(M PCA)Cumpllartce <br /> Insp�ctlon Form 1br Existlnq Suhsutiac�5ewage TreatmentSystems.Obseroatiorts,irrtarpretaiians,and conclusions musC be <br /> completed by an Inspector, malnt�Iner, or serolce provider_Comple#od Parrn must he submltted to tho(oCel unit oF gavcmmen4 wlthin <br /> '�5 days. <br /> Property owner,�am��s); Ja�es and Mog�an aay+ian <br /> Property address: 575 North�emdale Road UJeyzala,N1N 55391 ^ <br /> Properiy awner's addr�s(ifdifferent}: . <br /> CountY: HenrrePin , P��erty owner phone: 952-4D4-1553 <br /> I hereby certily rhat 1�ersonally rnede the obsen+etions,inCerprefstioRs, an�i con�ruslons report�al on thls forrr,a�d Ehef�h�y ere y <br /> coired. <br /> N�me. Jartles Brasgelmnnn __ . Certlfic�tion n�imbe�; <br /> f3uRinow ticense name and number; Elinar J,Petsrson Co. Lic�nse#�'19 a� <br /> Nams of laca n govemrnent �Y <br /> Sign�ture; ��� _^ —�� <br /> ��/ Datee: �J�'1517 D 4. <br /> www.pcast�[�.mn,uc . 55i-296=6300 - �OU•6B�•38ea . TTY b51•203.-3332�r 8�0-657-366a • AvAilable in altefnalf�e forma4s <br /> �+�q•wwisr.�a-�f . �r2a�n5 <br /> Pc3e3�f8 <br />