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07l3612909 21:14 7634975911 SPTESTINGINC PAGE 65/09
<br /> Ju1.29.200� 07:03 AM EI�R J PETER90N CO 76397?7��7 pAC�, 2/ Z
<br /> Perc�ll number 9ystem at�ttus� �C�omplionl �Nnnbbmpljqrri
<br /> (es d�erif�inad byfhls fbr►»)
<br /> Tank Inl��r�and Safely CoenRl�anoe- Co►�pNance/nspec�ion Fonn for Exiating S3T5
<br /> Compliance �ssue #Z of 4
<br /> Date af obse�valion; 7IZ8/0B Reason tbr obeeNation; Po�t of 9ala
<br /> Thfo form e�ires on(three yeere); 7128/12 T.... �~�.
<br /> Compliance qubal�JonsJ�HteMac(Requlred) VeMflc�llon Method":(Op�tlonal)
<br /> (CJ�eak th�apnr�a'lata b�.,._._ (Chuck tha aPAmOrl9le box)
<br /> Does ihe systsm ecnsist of a saepape pit', (a Yes �Nn p proqed tenk bohom
<br /> ass o II or laAchi ���
<br /> Do sewa tnn s le�k below�hsir ❑ Obsened low liquid leval
<br /> arlY p� k( ) r]Yes �No
<br /> dnsi ed arenn d� ? CI Examined weelruction receMa
<br /> Ityea,idenlify which ~ � Exsmin�d ampty(Pumpa�lank
<br /> sewags t�nlc In.aks,
<br /> My'yas"enawor Ina�caton ww�e x�e�+at�n�l�f�n�n,p ro protect ❑ �0�d D1J�Ids tank for"black soil"
<br /> �aund watar ❑ P�anprp,/vacuum check
<br /> � seepega piu�n,a�uno 7aeo,�830 may be complient If allowad � p�e� ""—""""�� —•- �,T
<br /> In ordnance by lacal pgrmftting sutho�lqr, _,,. ., , ,.� , .�
<br /> '"!Vo afanabrdprofocol�d�ta.7ftfa Neels nor axnsusrlw,fn.y
<br /> sequerdlel ord�;nordbsa It wd�coro wMa�h oombrnallona
<br /> 9re neceasery ib rnake fhls aAtt�nnlnAHo►1.
<br /> Safety Check
<br /> 1, A�e malnlenanae hala e�rer�damagetl,cradeed,or ap�red b be ahucluraly unsound? [J YesR �No
<br /> 2. Wers meinten�nae no��vara r�plscad h a eecvred n�nne�(e,g,�acrews rpPl�lc�7 �ifee [J No'
<br /> 3. VVas sacondary acoeas roslrak�t proaen!(sefe�fy pon,semnd covRr,nr eaFdty netHnp)—highy reaorm�ended, Q Yes��[]No
<br /> 4, Are othar sefely/Itcollh Issub preeenl7 ❑Yec• �No
<br /> F�cplein• � ��„ ,. „ �..
<br /> "�ysMm l�s an IntMlneAt thrr+�t to pubNc ha�►sed aq/ety.
<br /> C�rtific�tian
<br /> Thie inrm i�ro bP axnpl�ted and aUached to�he Summery Fam of khe Mlnnespta PdluBon Conqol qgancY'�(MPGA►Gprnpll�nea
<br /> la�cdon Fam for Fatlsang Subsutt0op 9owape Trealmont SyeMm�.Obeervqtions,Inteipreta6ona,and cnn�lueiono must be
<br /> 1�mpleted by an Inspsctor,malntalne►,or seivk�p�ovlder,Compieted form rrwst be submilled 10 Iho loaol unft oP�uvemmenl wilhin
<br /> �•
<br /> Properfy owner nAmra((s); t�aVe Kingrt�+n
<br /> p�ny addross; 1100 Kndl Manor Rd. Orono .
<br /> .. ,., ,_.��_.
<br /> Proparty owrisrs address(II dlMarenq; , ..
<br /> ,.,
<br /> County: Wennapin.... , Properlyawnerphone: ���-28�-3636
<br /> I hergby ce►t(ry thet I per8o�ally m8de the observsNen�,Mt�pr�(Jo�s,and condudans�epolted o►1 th/s/orm snd thst they e�
<br /> C0/IBC�
<br /> Name: James Braegelmenn � _ CertlAcaUon numb�r.
<br /> • _, _..., , .,.,.�..—
<br /> Buslneee aoon3s nanr,pncl nurrtbe�: Elm�r J.P�tnroon Co, �.ioen�+#9.�9 _ v �, er
<br /> Neme of it povomment• _
<br /> .
<br /> 3lpnature: _. _ Dete: �'/��
<br /> www.p�.stete.mn.us • 6S1•�96-6300 • eoo•b9?•38W • TTY 65t•Z82-S3d2 or AOD�697•3861 • Avatlable in altematlwe formab
<br /> wq-wwlsnwi-i1 • 4124109 Pone 3 of 0
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