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12/e812010 09:57 7634988290 RUSTYS PERC TESTING PAGE 64 <br /> Paresl number: Sys�em etatus: �Compllent ❑Nonoompwent <br /> (as determined bY this 1f�rm) <br /> Tank I�sprity and Sah�ty CanP�lane� <br /> Compiiance Iss�#Z o�f 4 <br /> �s�e of obeervation: _�2Jai20�o Reas�on for obs�lon: r� <br /> I <br /> This form e�ine�s on(thres llea�s): 1?J032010 <br /> Compli�nce questionalc�i�erl�: (Reau�� VvMficatlon Method`*:(Opttonal) <br />' Cl�dlt dhs riele hox (Ci+edr th�eppropriete box) <br /> Does u�e aystem consist ot a seepage pit', D Yes �No p Probed t�rdc boucm <br /> �°r � ObsafYsd low)iquid le�rel <br /> Do any sewape�^k(s)I�C below their ❑Yes �Nfl � ����rd6 <br /> des' � <br /> If yes,identity which s�we9e ❑ Exemined emPtY G�P��ank <br /> tenk lealcs. ❑ Probed outside tank for'blacAc soil' <br /> Arry°�r'eraw��Inal/cab�s th�t�e systwn�s fiiUng�p�t [] Pressure/vacuum chedc <br /> ��� � <br />� � � <br /> • s��cs�7oao.2�o may�co����rf suo�d <br /> in a�r�anoe bY I�I petrt�n9 sutl'°rity. <br /> i "'No slanderd P�db��ol exists.This Nst is nat exheustr�re.in <br /> i sequsntial o�e�,nur dbss�t lne6caede whkal�� <br /> �,�osssa►r ro�r��a��� <br /> Safe�ty Check <br /> 1. Are eny maintermnoe hole mvers aameped,cr�daed,or app�eared to be swcbu�ly ur�aound? ❑Yes' �No <br /> 2. Woro all maintenanae hole oavers rePlaoed in a sewred manner(e.g.,all scraws reP�aced)? <br /> �Yes ❑No" <br /> 3. Was seaondery acoesa restraint present(saiety Pan,seoond oo�rer,or sa�ety netdng)—highly rooanmended. ❑Yes �No <br /> 4. was�r othe�$efelY/I�e�l�h�P�� ❑Yee' �No <br /> �"� T�...�.. <br /> "Sy�fan�aa NnnNi�.nt th�b�pubrf�h�ald��nd aaAefb► <br /> Certification <br /> This form is to be completed and attached�the Sumr�ry Fonn ot the 1�inneaotia PoAution Control Ag�s(MPCA)Complronce <br /> Inspectlon Form for Exlstin9 Subsurtace 8ewa�a 7neatmer�t Sy�ems,Obeervaticns,in�rpretations,and conclusions m within <br /> compiebad by an Inopector,maintai�r,or service provider.Campleted(orm must be submilted to the locsl unit of govemn�ent <br /> 15 d�ys. <br /> property vwner name(s): N18tt&Cartie VsnSloo�en <br /> properiy addrsss: 3&W Jaoobs N�I Road Orono MN 56356 <br /> propeAy ownere add�ss(i��iRerenU: <br /> Courdy: _ Hennepfn Phor�e: 612�0�6022 <br /> 1 her+eby oertily that 1 personeUy made the observaU�ons.�nterp�etaEions, and condusloRs►+epo�ed on this l�rm end tt�at th�y are <br /> camsct. <br /> Name: Joseph J Oleon CordAcatbn number: 1255 <br /> Business lioense neme and number: Rus O{son's soil and �ivn testl Uc#B10 � <br /> Name oE locel�it gotie�r�r�nt Cit�►af Orono <br /> ��: Dala: 1?./OB✓'10 <br /> ,,,,�,,,,r,;��� Compliance Ir�spectlon Fam forFxlsNng SSTS <br />