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_ � .o7.i��i2oio io:27 rF�a -- '��F� (�ooiiooi <br /> Jul 12 10 10:25a TIM 95� 1882 p,1 <br /> 07I@e/201@ 01;08 76349�5011 SPTES'FINGING rr-w� n.�i+�i <br /> � �1'f�1 . 1'�~N,��� <br /> �arcel nurnbPx: , system statas: �Com�liet�t ❑Noncampdant <br /> /A¢[l�rtA�mif►�r4 Mr fbka N um I <br /> T�nk Integr9�yr ahd 5ltf�y Gotnplisnc.� - <br /> /�wrM►a���a,t�es I��.a.� iF7 nC A " <br /> �......r.�M��.... .��..� �.� .,. -. � - <br /> Date crFobs�rvaCro� �--17 - C>i � Reason fo�observa!'wn: �'rc11 �s��:..�-2 sc�t�- <br /> This tarm expires an(threa pears): _ <br /> Colt'�pliance qu8stioeslcHierFa:(Fteqs�red� Ver$ldation Methoul"'": (dptlon�} <br /> �Check the avAropriate box (C�eck tho appmprr ate bax) <br /> Does the system r.�rtsist af a seepage pit`. 0 Yes �No � Probec�tank bat�om � <br /> cesspoal,drvweU,or leachin�p"rt? <br /> ❑ 4hsetved!ow tfc;uld ievel <br /> ao any sewage tan[c(s)leak befow their �Yes No <br /> tieslgned o��de h7 ❑ Ezam�ned can�'uctia�recards <br /> Ii yes,idenMy which sewage � 6caminee!empt��(pumperi�tank <br /> tank Eeaks. ❑ Prflbed outs�r�+aRit far"black sar�" <br /> Aay"�s"answerindfcates thet the syste►r�Fs faFfing to pratect <br /> gmuedxrater, ❑ Pressurelvacuuin check <br /> [] Qther: <br /> ` seepaga piis meenng iuo`u.��u may p�compirani ii ai�vweo ---__..._.--- <br /> in ord'+nanoe by bcaf permitting euftiwity. <br /> "JVo stertdatd pmfocoJ exists.7'hJs list is reat exhausfrve,in <br /> aeouerttie!order, rror does h fnCfloafe whfch caunbinatk,n,c <br /> • atE necasssry fo ma�;e Fhls tiet�+rm/Retian. <br /> Safe�ty Check <br /> t. Are arty main#anance hole twers demaged,crac3aed,er eppesred ta be strueturally u�so�md7 ❑Yes' '�No <br /> 2. wem a1t mairtt�r�anee hole eovets realac�4 In a secut�d manner(a�7..ait aaews teplac�d)7 �Yes i_1 No� <br /> 3. was secondary access restreint present(a�afetp Pan,secorxt caver,or eefety netyng>-f�ghly�ec ornmarscsd. �Yes �Na <br /> 4. Was any ott+er QafetyR►eaUh tssue pregentT �]Yss" �No <br /> rxpiaa�: <br /> '3ysiem is an imminsni aersat io�uniic nsaim anv saie"ry. <br /> Certificatio� <br /> Ttfis form ts to be carnpleteQ and 2�tached to ths Surnmary��r�n afihe NUrsnesota Poflutian Can:no!Agency's�tPGA}Comp#tanee <br /> �----��__�_r.--�-�--•__...-�-••1--- <br /> retaErewuv��rv�w�wr caunurn3 aaayefUrRfct o��tiis��yC i icaviieii`v��i800�ny,Vo3oiV3pp(76,jfRE{'j)��LdppnS�&i'IU CO[1CIU31DRS fI1U9[OQ <br /> compl�tetl by an inspe��r, maintainer,or secvice ptavider,Corttpteted irnm must be subrrtStted ti�tE�e locai untt oi goueritmetsi wdhin <br /> 15 days, <br /> Propertyownerc�ame(s): ��>✓t�c..✓� �,���rl.�,�" i'F <br /> Property address: �S Zo �c� SF-s�e c� !^,c-v rti.o i�c.J �'S"'�i`� 1 <br /> Properip ownef s gddreas(a dlfRerenty: „_ - , .... . � <br /> County. ,�G�vLe i+� Phone: �SZ-L!7 3- 3�L L9� <br /> �har�,by certily�&t 1 persanelly made ftie a6servatlons, fraFerpt�tations,and cancfuslons report�!on this hwm ar�d fhat they are <br /> conect. <br /> .,—� <br /> idame: L i�,^'� �,ii,l �,l�G-n CertkflcatrOn rh�mDer: E���� �v ` <br /> Business tice�39 name an u�ber, t,:., ��s�s.-.�v� � C?, _)r • �/'. � � �� � or <br /> Name vr loca!uNt at r ment: (� �,�,r�o <br /> S�gneture: .,. oete: 6--! �7-, Zc�1:i7 <br /> � � <br /> wq-wwlstt4-31 _ Ca»pfianCu lnspection Form for Exlsting SStS <br /> 41tl08 . <br />