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Oct 15 09 �8: 19a Rndy a Julie Kleindl [9521 -44�-9z81 p. 4 Parcef numper. System status: �`Compliant ❑ Noncompliant (as deteimined by this form) Tank In�egrity and Safety Compliance Complia�ce Issue #2 of 4 Date of obs�rvation_ _^�Q=�-�._.__ Reason for observa#ion: ��Q P This form e�Cpires on (three years): _ Complian e questionslcriteria: (Required) Ve�ification Method*`: (Optionaq (Chec�fhe a rn riate box (Check the appropriate box) Does the system consist of a seepage pit', ❑Yes �No ❑ Probed tank bottom cesspool,d ell, or leachin it? Do any sew�ge tank(s)leak below their � ❑Yes � No ❑ Obseroed low liquid level desi9ned o eratin de th? ❑ Examined construction records If yes,iden fy wt�ich sewage �' Examined empty(pumped)tank tank leaks. I ❑ Probed outside tank for"black soil" Any"yes" wer indicates thaf the system is fallFng to protect grqund wa r. ❑ Pressure/vacuum check ❑ Other: ' Seepage its meeting 70802550 may be compliant'rf allowed in ordina ce by local permitting authority. "No standard protoco!exists. Thrs list is not exhaustive, in sequential order, nor does it indicafe which combinations are necessary to make ihis determination. Safety C eck 1. Are an maintenance hole covers damaged, cracked,or appeared to be structurally unsound? ❑ Yes` �No 2. Were a1 maintenance hole covers replaced in a secured manner(e.g.,all screws replaced)? �Yes ❑ No'` 3. Was se ndary access restraint present(safety pan,second cover, or safety netting)-highly recommended. ❑Yes f�"No 4_ Was an other safety/health issue present? ❑Yes` �`No Explain• *Syste is an imminent threat to public hea/th and safety. Certifica ion This forrn is o be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's (MPCA)Compliance Inspection ortn for Existing Subsurface Sewage Treatment Systems.Observations, interpretations,and conclusions must be completed an inspector, maintainer,or service provider. Completed form must be submitted to the local unit of governrnent within 15 days. Property o er name(s)= Property ad ress: 763 Femdale Road North, Orono MN Property ow ers address(if d'rfierent): County: enne in Phone: 612-781-2321 1 hereby ce ' that I personally made the observa�ions, interpr�tatrons, and conclusions reported on this form and that they are correct. Name: drew Kleindl Certification number: 2926 Business li nse name and number: Jim's Excavating 8 Pumping,LLC or Name of lo I unit of govemment: C rver Coun Signature: _ Daie: /� �