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01/31/2012 14:31 9528733112 PAGE 03106 <br /> � <br /> Parcel number: System statu�Compliant Q Noncompliant <br /> (as determined by lhis form) <br /> Tank Integrity and Safety Compiiance <br /> Compliance Issue # Qf 4 ��:��� <br /> Date of obsc�rvation: f _� Reason for observation: _, . ___„ <br /> This form expires on(thr E years): _, ,�„_. .... . .-- <br /> CamplianCe questionslcriteria: (Required} Verificatian Method`*: (Optional) <br /> (Check the sppro riafe box (Check the epprQpriato box) <br /> Does the system consist of a seepage pit', ❑Yes �o ❑ Prob�d tank bottom <br /> cesspool,drywell�or leaching_ it? <br /> ❑ Observad low liquid level <br /> Do any sewage tank(s)leak below their �Yes �No <br /> designed operating depth? �xamined oonsttuction records <br /> If yes, identify which sewage __ ��xamined empty (pumpod)tank <br /> tank Icaks. ,_ ❑ Probed outside tank for"black soll" <br /> Any"yes"aAswer indicates thaf the system!s failing!o protect � P�essure/vacuum check <br /> ground wafer, � <br /> ❑ Other: N �.� T., <br /> ' Seepage pits meeting 7080.2550 may be compliant if allowed <br /> in ordinance by local permitti�g authority. -� •--•••-••�- <br /> '*No sfandard protocoJ exrsts, Th�s/rsf is not exhaustive, �n <br /> sequential ordei, nor daes it indicete which combinafions <br /> a�e necessary to make �hls determinatron. <br /> Safety Check <br /> 1, Are any maintenance hole covers damaged,cracked, o�appe�red to be structurally unsound? ❑ Yes' �No <br /> 2. were all meintenance hole�overs replaced in a secured manner(c.g..all screws replaced)? �es ❑ Nb' <br /> 3. Was secondary access restraint present(safety pan,second�over,or safety netting)-highly recommended. ❑YeS No <br /> 4. Was dny other safetylhealth issue present? ❑ Yes' No <br /> Explain: _ .. . -..- -� <br /> "System fs an imminent ihreat to pubfic health and safety. <br /> Certification <br /> This form is to be campleted and attached to the Summary Form of the Minnesota Pollution Control Agency's (MPCA) Compllance <br /> inspectlon Form for Exlsting 5uhsurFace Sewage Treetment 5ystems. Observatlons,interpretations, and concluslons must be <br /> �ompleted by an inspector, maintainer,or service provider, Completed form must be submitted to the local unit of govemment within <br /> 15 days. <br /> , <br /> Property owner name(s): _ _ -----.� - � <br /> Property address: _,,, _ . _,s � � - --�— <br /> PropErty own�ddress(if different): .. ... - <br /> � ' <br /> County� Phone; , , ._.__.. <br /> I hereby cerlrfy that I personally made the observatlons, interpretafions, and conclusions reported on #his form and lhat fhey are <br /> correct. <br /> Name; �� _„ L �l� __ Certification numher: ���.0�_ , ,___.__ <br /> Business license name and n ber: Ud,�����5 11��••� _. _ �S�o�. ._....__� or <br /> Name of local un gove ment; .. .._ — - • <br /> Signature: __, Date: ,_ �,.��^ <br /> wq-wwisCs4-31 Comp(iance Inspecrion Form /'or Exisiing SSTS <br />