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Parcel number: _ System stakus: �Complian# (] Noncamplianl
<br /> � (t�s defem7irled by this form)
<br /> T�nk Imfie�r���/ �w�ii ������ Gornp�earnce
<br /> C�mplaan�e Nssue #z af 4
<br /> Date of obsenraiion: ____ 5�)� p� 1'2eason for observ�fion- ���'�c�,.�� -��' 4��y�" "�_ _
<br /> �
<br /> T�,is forrn expires on (three years): S _ f -� �!_.1 �...._._,..,..,.�._.,.,�_,,.. ....�_.".,...
<br /> Compl�ance qUes�����IG�rp�er�a: (Required). , Ver�fRcafinrt Methoc9**: (Opfiongl)
<br /> ,___ (Chsck fho approprfafe box (�laeck tho�ppropriata box)
<br /> boes the system consist of a seepage pit", [�Yes � No �
<br /> ceaspoal,drywell, or leachin it? ❑ Probed#ank bottom
<br /> f�o any sewage tank(s) leak below their �Yes � Nd ❑ abserved low liquid level
<br /> , dosignod o ep rating r,(e th? � Cxamined construction reco��ds
<br /> If yos, idonlify which sewage � Cxam�ned enipty(pumped)tank
<br /> tenf<leaks_
<br /> ❑ F'rohed nutside t�ntc fur"black soll"
<br /> Any"y�s"�nswcr fndFcafes that the syst`ern fs faVlfng to pro4�ct
<br /> gmi��nd+nrnt�r. ; � 1'r�ssure/vacuum checfc
<br /> ' Q �iher:
<br /> ' SPe�aage plks meeting 708U.2550 may be cairpllt�nt lf allawed ; �'�-'� -
<br /> in ardinance hy local permllting�uthorify. � .�__,__�_W,,.�,�,..,,�,.,.W„_,^__... M,�
<br /> ""No i3tpndard protoco!ox)sfs. Thfs list!s no(exhei�sfiva, Jr7
<br /> seqA�entia/orrk�r,nar daas it ir�dicate which combinatia�s
<br /> , are necessary to malce 1l�Is determrnatlon.
<br /> $afiefi� Check
<br /> �. Are any malntenance hale co�ers damaged,cr�cked,or appear�ed 10 be stnicturally unspund7 ❑Yes" � No
<br /> 2. Were all malntenance hole covers rEplaced in a secured m�nner(e.g,,all screv�rs roplacoc!}; �Yes ❑ No*
<br /> 3. Was s�conrlary access restraint present(safeiy pan,seaond covar,or safety nettEng)-hlghly recommended. ❑Yes
<br /> � No
<br /> 4. Was any othor safaty/health IsEue prasent? �y�g* � ��o
<br /> �xpl�itt:
<br /> "System is�tt rmminent tlrreat t4 public l�eal[!i an[I s�fety.
<br /> �flf t1�1C8X10�'1
<br /> This form is tv b�campleted and att2ched to the 5ummary Farm;af the Minnesota�ollutfon Control Agency's(MPCA)ComplNance
<br /> Inspection F�rcn for�xisting Subsurtace Sevw�c�e Treatment Systdms. Obs�jrvations, interpretations,ancl canclusions must be
<br /> completed by�n inspectar, nialntalner,ar seruice proulder. Compl�ted forrn must ba suhmitted to the local unit of governmenf witliin
<br /> 15 days,
<br /> Pranerty awner name(s): �'{'�t��,- ���,,.l��-� �' ^_ ^ _ ,._
<br /> Propert�r 2ddress: -----)-�5E, S �'�9.1(,.� C,-���°,/�, G>.�,�C�
<br /> ,�.�a,��_ _..� ...—
<br /> Praperty awner's address (if dir�erent):
<br /> County. ������.�-� ---��- Phone; ��� -,.._�
<br /> , ..���.'� r' 4"��__.....
<br /> 1 l�er�ebVi ce�iily lhat 1 pr�r.sn,nally madP fl�e ohservallotas, Ir�ferpret$tinns, and corn:l�fslons reported on thls fon��ai�cf that they are
<br /> cnr•rect.
<br /> Plame° _�rr,��1�F-�.l�Js S��'��✓•y�.� ._,� Certific:_atlon rzwnber: _ (��rJ _^^� ••-
<br /> E3i�siness ifcense nam4 and number: �T'�'_.'"��.�'jJl_�-I����.,��.,,��_�'�.�-}�r"7�s�"�-�.��=�_R.�(c�..� or
<br /> Name of loc�i unit of governmeni:
<br /> Slgnaiure: �� �7a, �.:LL.:` — - _ faate: '$�rt'1�- O `� � .
<br /> tivq�tvwisrsq-3f Compliante lnspettion�orm for Existino SSTS
<br /> 4�r�o�
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