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06/08/2010 23:37 7634975011 SPTESTINGINC PAGE 06/13
<br /> Jun.04.2010 11.15 AM ELMER J PETERS�N Cd 763�7272�7 PAGE. 2/ 2
<br /> Parcel numbAr ,^ _ .,,,,,�� Systam RtAtua: �C�mpliant f,a Noncemplion!
<br /> (es c/stem�ln9d by thls Ib►mJ
<br /> Tank Integri�y and Sa#ety Compl�an�e- Compliance InspecNon Form for Existing SSTS
<br /> Compliance Issue #2 of 4
<br /> �ate oPobaervaflan: 612/1U Reweon forobserv�tlon: Requestirom Homeowner
<br /> This farTn qxriree on(lhree years); �10 w� _,. y� „_ . f M.� _,.....» w.._ .
<br /> Compllance q�estiotls/criterie:(Requirod) Verifioatloh Metllad"":(Optlanal)
<br /> (CAeck the,ap�rop7�t�bek) „ _. (Cryoolr tN�appropNa�e box)
<br /> Doo�th�syslem consisi oP a seepag¢�plt"' ❑Yas �No ❑ prab�d tank bo�tom
<br /> cesspoo_I,drywell,orleachln�ptt? __. __._
<br /> Do�ny ccwage lenk(a)leek below iheir I�Yes �Nn Q Observed low liquid lovel
<br /> daeigned operolin��th7 _, ,, ❑ Examined construction r�aards
<br /> -If yes,identity wf�leh . _.._ � Exnmined emplY(pumpec�tank
<br /> aewago 4ank Iseka.
<br /> .-----�• �•••- ❑ Probed oumld�lank!or"black ao�i^
<br /> Any"ycis"n►rswor indlcsfea that Nfe syrrtam i��q�llnq fo prolecf
<br /> groundweter. ❑ Preoourelvoouumcheck
<br /> 0 Orher;
<br /> ' Seepa�e pita me9ting 7i�80.2350 rnay be aompliant If aflowed " ""
<br /> in ord�n�noe by loeal permltling awth�rlty. __.. , . ,.
<br /> "No fifAnder�dprotocol exlsts.This list ia naf exheueKue,!n
<br /> aeqilanflel e�dor,nor does It Indic��+wh�ch comb(nadons
<br /> e�rl�oaesery�o make fhls dete►minr�6on.
<br /> Safety Check
<br /> 1. Are malnt�nen�hole covere damaa�d,crecked,or appea�d io pe stn+c�ur�lly uneound7 ❑Yes' �No
<br /> 2, Wbre maintana�oe hole covora replaced In���eured menner(o.g.,ecraws replaced)? �Y�a []No•
<br /> 3. Was secand�ry aoaess nestroMt present($atety pan,e�cend wver,or saP�ty neltinQ)—hiphy recommended, ❑Yeg�j/g]No
<br /> �'L
<br /> 4. Are other safetylhealth issu�pec�entl ❑Yes" ���No
<br /> Cxplsln; ,.,,. --- -,,,,..�-�.._- --• , ,.. _ _.,. ,_�,
<br /> +&yA�m!e an lrrfminent thregt!�o publio ha�lth and sefety,
<br /> Cer���Ficax�on
<br /> Thls fo�m Is to b9 completed end attached to Ihe 5umm�ry Fnrm of tnc Mlnnesole PolluNon Confrol�goncy's(MPCA)Co�npGanc�
<br /> Inspection Form for ErisNng 9ubeurfa�a 9t�wnge Treetment Systems,Obacsroalione,Interpretatlons,and oonalu�ion�muet be
<br /> complotod by an Inapector,maimel�ar,OP 9orvloe provlder.Compleied fomt mu81 be submltted to the Itleel unit of govemmeni wHhin
<br /> 15 days,
<br /> Property wvner name(a), Dave panlelc+ ____w .� _
<br /> PropArty eddrass: 710 Oander Rd. Qrono,MN 55�91� , �
<br /> Property oWlter'9 addr9sa(If diiforent)� � .,_. � _.... .�„ ,.^,.�
<br /> County: Hennepin property owner phone; 952•484-6677
<br /> 1 haraby c��tffy�Aat I�erso�ally r+�Atle ths observeUons,lnte�prefaflons,ane conduslons�palted on H�io fbrm end that they nre
<br /> correct.
<br /> Name: James sraegelmann CertlHoetan number.
<br /> Buefneea lioense name and number; E1mQrJ~Peterson Co, licen�e1�,219 _ �+� _ _� �M or
<br /> Name of lon i of govamment;
<br /> SignAiure; �_ Dato: 6/2110
<br /> ,,,. _.� �..�—_,._
<br /> www,pcn.stRte.mn_us • A51•7.96�6300 • Bo0•537-3136+1 • T1'Y 651-282•9�72 ar 800-657�3e64 � Avntlnhle in alternative formab
<br /> wp�wwls0�1-]I • �/Z{/09 Paye 3 of 8
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