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_ , <br /> . ,-`T + - status: L7t►orr+Pf�aM 0 Noncompliant. ' <br /> P`arcel n�mber. - . • �� . <br /> , � . � � : - fas determin . • . - <br /> _ . - . ���_� � . <br /> . - - ����k���.�� <br /> Tank integrity and Ssfety Compiiance - - �'��' ���.� � � . . . <br /> , Compliance Issue#2 of 4 � - . � - - � <br /> r <br /> D�te of observatiort: �^�r-/ _� Reason for obsenr.adon:. : <br /> �� This fortn expires on(three years): �=�f'`/ � . <br /> Compitance qu�tionslcr.i�rla: (Required) � Verification Method'"':(Op�onal) :: . <br /> cned�me� � �aie"vox � - � �che�me apPro�Rare nox� . . <br /> Does the system consistflf a-seepage pit•. ❑Yss� [�'I� �bed tank.bottom . . � <br /> �cess d il or leachin ' � • . ,,.�,/ � _ <br /> Do any sewage tank(s)leak bebw their. �[�Yes � � .�����low tiquid leve{ � . : . <br /> des' nsd o ratin de th? ` I�-txa � ed consiructlon records . � - <br /> If yes�identiffy which sea►age .- . _. Examined emPtY(Pumi�ed)tank - : _ . <br /> tank leaks. . - , - . • . - <br /> Any`�es"answer fndlcatas that the sysfem Is falling to protect . � Probed.otitside tank tar"black soi!° <br /> ground water. . � - ❑ Pressut�e/vacuum-chedc �,, � �� <br /> . _ . . ❑ Other. 3^'� ° ° a �r./-�_ �� -. <br /> • Seepage pits�mNting 7080.2550 may be compiiaM lf albwed - . —� . � <br /> in Vrdinance by.txal permitdng'sufhoriiy. . . . - --, <br /> , � � • � � "No sta►�dard prrotoco/exists. This list is not exheus'�ive,Jn � ` : <br /> � . . _ � seq�a/or+der,nor does it Indicate which c'ambina�s . . <br /> � � are necessary to�inake.this deterininatTon. ' <br /> : .Safety CMeck � � � � . - � . : . � � � : <br /> 1. Are atriy maintenance hole covers dsmaged,•cracksd,or_appeared to be structurally unsound? �� []Yes* -� �� ' - <br /> �2. We�all�maintenance hote covers replaoed in a secured manner(e:g.;aU.scxews reptai�d)? ... . e� ❑No*� <br /> 3. ' Was secondary ac�ss restra�M preseM(safety pan;sec�nd coirer,or safeiy netting)-highly r�ecommended. ❑`Yes � � � . <br /> 4: Was amr other aafety/health issue p►�eserrt? � . . - • .� . � ❑Yes' �o <br /> . Explain: . • �- _ . <br /> *System is an Immtnent threat to pt7blic heatffi and safety:� . - . " - <br /> Certification � . . . . - -. <br /> This fo"rm is to be c�mplefed and attad�ed to the Summary Fomi of.the Minnesota Pollution Controi Agency's(MPCA)-Compli�nce � <br /> tn�pection Fonn for Ex�sting 8ubsurfacs Sewage�Treatnie�t Sysfiems.Observat�ns,interpretations.and conciusions must be..�. - <br /> c:ompieted.by an inspector.maintatnsr.or servtce provi8er.Compieted foRn must be submttted to the local unit.ot govemm�nt within . <br /> 15 days. � . ' . - <br /> n -D I � . , . - . . <br /> Property oumer name(s): - K O r Ir� � A�l U, _ . <br /> Property address: �o e� N- ►a ►��t�r�� �P a �s , .�C��o �,v �M� �5 5�-q�J . - <br /> � Property owne�'s address(if di�ferent): � � <br /> • County: p YI n, L°� • Phone: - <br /> ' . - . . <br /> 1 her�by certify that t personally made the observaSons, interpr+etefions, and conclusions�sported on thls form and that they are � <br /> coinacr - . - <br /> Name: � [a R �.e, .�� {'��` Certificabon number. CP�a G 8 � ' : <br />� Business i'�cense name and number. l r.rr.n�� �P��i-c � r vi��: LL•L�- - �S�� or _ : � <br /> Natne of iocat un vemmen� � � � . <br /> Signature: Date: �'"'y^/�_ . <br /> wq-wwlsts4-31 � . � . tompticnce tnspectfan Farm for Exfsting SSTS <br /> er�intt � � <br />