|
05/27/2011 e2: 21 7634975011 SPTESTINGINC PAGE 07/11
<br /> ,�,. _., � .,..,.,.,� �n��c� �,r hieiaui i�u, /Ei3•5!/J..'I'l17 p,?
<br /> Parcei number. T_` , 5ystem status: J�Compliant ❑Noncompliant
<br /> (�s determincad by this farm)
<br /> Tank I�ntegrity a�d Safety Campiiance-- Com,o�lian�e lnspectlon Form fiorExisling SSTS
<br /> Comppiance Issue#Z of q
<br /> DE� oFobservatfon: 5113111 Rcason for o6�Pruation: pa�t af Sale
<br /> This form expir'es on(thl'ee yee�3): 5113/11 M_ .... ., ^
<br /> Compli�nce questionslcriter7a: (R�quired) Verificat�an Methad"":(Opticnal}
<br /> Check ti�e a a rlate boz , (C�heck f.f�te approprrafe box)
<br /> f�oes the system consist ot a a¢apage plt', p Yes �No � Probed t�tnk bottam
<br /> ,ces�p�ol�drywelf,orleaching pil?
<br /> IDo any�ewage tank(sJ IQaI�below their ❑Yss �No � Observed low Ilquld lovel
<br /> designed operetinQ depth?__.,., ❑ Examined consCruction records
<br /> If yss, ida�tify which ❑■ Examined empty(pumped)tank
<br /> sewage hanit le�k9. � p�abed ou�lde tank Por"blr�ck Foll"
<br /> Ar►y'yas"answer f►1d�cat�s thst the systern Ps falUng to plot�t
<br /> grvurrd wafer. [� P�essure/vaaium ch�ck
<br /> ❑ Otlter:
<br /> ' Seepa�qe pils meeting 1080,2550 m�y�e compliant i�f allov�ed �
<br /> in ardinance by local permlttf�5}autho�ity, _____�„„_,,,
<br /> �No 4tPndordproMcof o�fs_TP�fs llsf is noP exhausb'vo,In
<br /> seque�U�l order,n�r does 11�ndicef�whreh carnbinntfc�ns
<br /> �,re nacec4�b maha fhfa datBrmJnatlon.
<br /> 5�fety C�e�k
<br /> 1 Are meln�tenance hole oovers damaged,craclaed,or appaared[o be slTur,b�r211y unsound? ❑Yes` �f No
<br /> 2. Ware rnairttenance halc oaversrapleced in a�Ecurod manne�(e.g.,acrev�s replacedj? m Yes (]M1lo'
<br /> 3 Wes seeond9ry access res7alrrt preserrt(safcty pan,�cand oover,0�sefety netting)—f�ighly reeomrnended. ❑YesN��No
<br /> 4. Are att�er safe�tyJhealth issue pres�nt? ❑Yes• � No
<br /> Explain- �, �.�� .,....._�.... ----�
<br /> RSpsre►n is an immrR�nt fhrae�to pubff�h6+allh arld s�fety_
<br /> Certifi cati�n
<br /> thls form�s to be completed and attachod tio ihe Surnmary�arm a�tl�a Mlnnesota Pollutian Ganfiol A�ency'�(MPCA)CornplianCe
<br /> Inspcctlon Farm for ExlsHnc�Subsurtaee Sew�age Treatment�ystems.Observabons, In�erpro�tlons,end conclusfons must be
<br /> ��mpletod by an m�pector, malntainer,or senrice prnvider, Complet�d form must be submitted ta t?ie Iocal�anit of gavernmerrt withln
<br /> 15 days.
<br /> Prnperty owner nams(s): 5andr�Deas _�
<br /> Pmperty address; 1260�rench�Cleek Drive We}2sta, MN 55391
<br /> Properly ownEr's qddres.{If dlffc�r,rrkl: ,r,,_ r,
<br /> CourAy: Hennepin_ f'rvperty avmer phano: 952�473-0638 �
<br /> �hereby certify that F persori�lly rh9de the observ�ti6iis,inf��pt�taUnns, end coRclUsrons renoR@d oh this fo►m e►td Ihet t�ey are
<br /> corr�ct.
<br /> Name: •�ames Braegelmann Certffication number:
<br /> Buslnos.911cense name�nd number �ImerJ.Pel�erso�Co. License#219 or
<br /> Nar�e of loc r govemment
<br /> 9igna#ure: �ate: 5/13h 1
<br /> www.pca.stat�.mn_us 63't-29G-d3�0 • B00-657-38fi�1 • TTY 691-28,�-933�vf$0�699-9gb4 • A��ilable in alkem�t;ive rormncs
<br /> weT-wwisls4-J! • 4/24/04 Paqe 3 af A
<br />
|