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07168/2011 01:16 7634975011 SPTESTINGINC PAGE 05/69 <br /> _lur 17 11 02;37p Cln�or J, Potor�on Co, 703-972-7217 p,')_ <br /> Parcel number. 5yskern slatus: 1�Comgliant ❑Noncompll�nt <br /> � W��� (�s determined by this fr�rm) <br /> Tank In#egrity an�d Salf�ty Campliance -- Camplla�ce Inspectidn Form farL-xisting SSTS <br /> Corn¢liance lssue #a of 4 <br /> pate of observetlan: 61'14111 Reason for observation: Polnt oi Sale � <br /> This form�xpires on{three}�2�15): R114/11 ____ ___ __�.,,, <br /> Complianca qu�stions/eriteri�.{Required) Werification N12thod`*.(vp�►onaq <br /> ___(Check the appro,�riate�iox (Chc�rck ihe 9p,aropdsle box) <br /> Does the 5ystem cansist of a Acep�yc pit', �YPF n Nu � Probe�d t�jnk bottom <br /> eesspaol,drywell,ar leachf�g_pI�L? <br /> [� ObseNed low Ikqu.ld Icvel <br /> Da any sewaAe tank(s)leak heloW thclr Q Yeq �Ji No <br /> ciesiqned eperating,depth? ^ ❑ Cxamined cans�ruction recordE <br /> If y�s, identify which 0 Examined empty��umped)tank <br /> sewage tank le2ks, ❑ Probed ouiside tar+k 1'or"b�ack�oil" <br /> Any"yes"answor tndlcaies tha�tha�s�srfYn is fal�png to pro�ect <br /> ground w�ter. ❑ PI'essuro/vacuum Check <br /> ❑ Othnr. ,_, _ <br /> ' Seepage pi�me�ting 70802550 msy be compliant if allow�ad <br /> in vrdinance by locel permitQng euthoriiy. - �•�• ----- <br /> "Nn star►da�d�w'otocol ezi5fs. This lis!i9 hot exhsustive,M <br /> sequenNal aNer,nor doas Itindir.a�wAlch combJnafions <br /> are necer,r,ary to malm Ihls deferminefiron. <br /> S�ai�etp Cherk <br /> 1. Are maintenanec holc c�e��damoged,�racked,ar appeared N be s'trucFitrally unsaund? ❑Ye�" �No <br /> 2. V1lere mslnCenance hale cavers r@placed in a sscured rnanner(e.g.,scsaws replaced�l Q Yes ❑No• <br /> 3. Wgs sBcondery access rc�tralnt present(sa?e'Ly pan,:+eco��oAver,or safety natting)-highly recommonded, ❑Yas�I�No <br /> 4_ Are other�'f8't,ylhealth issue p�seht? ❑Yes' �No <br /> �xp(ain: , .,, ----- -• ,� <br /> System!s ar�ImminPr+t chrsat to publlc h�lrh and sal�ry. <br /> Cer�ification <br /> Thls form is tr�he comple•ted and atfiaelimd ta the Summary Form o4 Fho Mlnnesot� Pallution Control Agency's(MPCA)Compllenee <br /> InspeCdoll Farm for E711561ng Subsu�'[ACe Sewage Tte�tlRteRt Sysbems.Observations, interpl'ctations,snd conclusionR rnu�t be <br /> ��nmpletEd by an inspector, msinfiainer,or service provirJe�.Com�lEted fflRn must be submltt2d tnthe loc�l unit of govemtnEntwlthin <br /> 15 day:�. . <br /> Properly awn�r name(s): Vicky Nann .,, .--. _ <br /> Property address; 1300 Franch Creek Orlva W�yzsta, MA155391 , „ <br /> Properry o�vner's addres-s{ifdlttarant): ___ - <br /> County: Hehnopin proper�owner phone; 952-T69-7Q59 <br /> !he�ef�y certl/y that 1 petSonelly mede fhe Obseruahorrs,interpr�t�tions, and oonolus�ons reporled on thi9 form ana ths#'fhey are <br /> corr�cf. <br /> �l�me� James Braegelmann Certification number: <br /> Business license name snd number: E�mer J_F'eterson Co- Licensc#?.19 et <br /> Name oF loc govemmerrt: ,, ._ _,. �—�•�^ <br /> D�{e: 81941�1 <br /> Signature; !. --- -�-- �._,. <br /> .� <br /> www.pca.slaCF.mn_us • G51-Z96-b30o • 800�557�38b� • TTl'651-Z87.-333�or 800•657-3R64 � �vallabl4 in allern�[tve formaC, <br /> w4-wwlsts4-31 • 4!Z4109 Poge 3 af 8 <br />