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I . <br /> Parce!number: � � System status: L�1'Compliant ❑NoncompliaM <br /> (as determine thi�fo�t . <br /> � � �81l�;s,:1��C��tVti:�,�.� � <br /> rr- <br /> �E3sQ2:3 Z�t�Pt. N� `� <br /> Tank lntegrity and Safety Compliance . �t� A!ticltaet, M�1�i 5��6 � <br /> Comptiance issue#2 of�4 � �. <br /> Date of observat'ion: /�- Z 7— l�� Reason for observation: �E° �����; 1.���'�-e-� <br /> This form expires on(thr�e years):� /�-Z y? � �� � <br /> Compliance questions/cciteria: (Required) Verification Method"":�(Optional) . <br /> Check fhe a rv riate box � (Check the appropriate box) � <br /> Does the system consist of a seepage pit*, ❑Yes �o �bed tank bottorri - � <br /> �cess ool,d ell cr�leachin it? . , . <br /> Oo any sewage tank(s)leak below their ❑Yes "No 0 Obser.ved low tiquid level _ <br /> desi ned o eratin de th? � �Examined construction recards � � <br /> If yes, identify which sewage , . Examined empty (pumped}tank <br /> tank leaks. � , [] Probed outside tank for"black soil" � ' <br /> Any"yes"answer indlcates that fhe system is failing to protect � - <br /> ground waf�er. ❑ Pressure/vacuum check <br /> . � . ❑ Other. � . <br /> * Seepage pits meeting 7080.2550 may be compliant if ailowed � . <br /> in ordinance by,locai permitting authority. _ <br /> � � '*No standard profoco/exists. This list is not exhauslive,in � <br /> sequential order, nor does it indicate which cambinations _ <br /> are necessary to inake.fhis defermination. <br /> : .Safety CMeck . � : � � <br /> 1. Are any maintenance hole covers damaged,•cracked,or appeared to be structurally unsound? []Yes* 1�J No � <br /> 2. Were afl maintenance hole cove�s replaced in a secured manner(e:g.;a{)screws replaced}? - . �?es ❑No•.� <br /> 3. Was secondary access restraint present(safefy pan;secohd cover, or safety netting)—highly recommended. ❑Yes �o <br /> 4: Was any other safety/health issue present? . � � ❑Yes�' L-TNo <br /> - Explain: , . �. <br /> *System is an immineni threai to public heaith and safery. <br /> Certification - <br /> This form is to be completed and attached to the Summary Focm of.the Minnesvta Poilution Con#roi Agency's (MPCA)-Compliance <br /> inspection For+n for Exlsting Subsurface Sewage�Treatment Systems.Observations,interpretations,and conclusions must be . <br /> completed.by an inspector, maintainer,or service provider.Completed form must be submitted to ihe local unit.of government within <br /> 15 days. � <br /> , <br /> Property owner name(s): O�w�a�'� ��� <br /> Property address: I.2,�O i��¢v+c�n C �-u iC ��. � -- <br /> Property owners address(if different): <br /> County: Phone: <br /> 1 hereby certify that tpersona//y made the observations, interpretations, and conclusions reported on this form and that tirey are <br /> coirect <br /> Name: ,1 1 �2� C � �1'�'✓' Cert�cation number. �-� �� �'`� <br /> � Business license name and number. l�r t(i i�r�� �F r��11' �'i`V i Cr� �-E,�°— - �t� �j __ or <br /> Name of Ioca!uni ovemment: � � <br /> Signature: � Date: j ��� Z 7 - /�1- <br /> wq-wwfsts4-31 . Comp(iance lnspectfon Form for Exfsting SSTS <br />