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63/22/2011 22:49 7634975611 SPTESTINGINC PAGE 05109 <br /> Mar 1511 OB:59� <br /> Flmer J,Peterson Co. 763 0�� ���� p � <br /> Parcel r+umber: System sta'tus: �1 Compl��nt ❑Noncampli�nt <br /> -- '°'—'� (as determinsd by thi�fom►1 <br /> �"a�k Iqt�grity a�d Safety"Complia�ce — Compl'ian�e /nspecfion Form for Exrstrng SSTS <br /> Gompliance Issue #'Z of 4 <br /> Daie�f observation, <br /> 3111l11 Re2son Forobservatir�n� Poin�oFSale __ <br /> This f�arm expires an(three years): ���!�T �- <br /> Verificatlon M�1'ltod"":(Optionol) <br /> Compllance questfohslcr�tena:(Rsquired) ro ri�(c hoK <br /> __ Check the approP���box) _ (Che�k the�PP P � <br /> paes the sqstem co�sist of e seepage pf�", ❑Yes [�J No 0 Probed tank bottom <br /> c�sspool,dtywell or leachin it? ----� ❑ Dbeerved low Ifquid level <br /> Do any�ewage 1Ank(s]leak below their C]Yes �No � Examined oonstruction r�cords <br /> designed oporating depth? . <br /> —�- � Eicamined emp'ly(Pump�d)tank <br /> IPyes,iden�fywhich <br /> sewage tonk leaks. � ❑ Probed outsida rank€ar'black soll" <br /> Any^'yEs"answerindlcafes Chat fhe sysfem!s(c�fling ta protecf � P��6surelvacuum check <br /> gro�nd w�ter. <br /> ❑ Other _.� <br /> ^ 8eepepe pits meeting 7060,25�G rnay be compNant iF eEl�wed <br /> In ordinance by locel pe�tnitHng au2hority, <br /> ••IWa sla�da►d protocvl oxi.4ls.This 1/st rs not axhausfive,in <br /> sAquende/nrder,nar does I!frr�rc»te whl.ch combinat;ons <br /> are nAcessarY fo rnahe(hr�dei��rminetion. <br /> Safety Check <br /> 1. Are mAlntanence hole covors damaged,crack�d,ar app�eared t4 ba struclur�lly unsound7 � <br /> Y@s' �No <br /> Z, �Nero maintenance hole cdvers rep�oced in�qecured rnannar(e.g.,¢crewr�rep�ac�d)? Q Ye�s []No' <br /> 3. Vl�as second�ry access restFelnt present(s��Q'�y PSn,second cover,or sefetyr nmtting)�highly rccommendad. ❑Yes���]No <br /> 4. Are othel'9A'�et�rlhealth lstue pressnt? ❑Yea' �No <br /> Explain: __ „_ <br /> •Sysl�+m iS an ir!'i+'►i.fnent th►�at topublic he�lth andsafery. <br /> Ce�trf�cativn <br /> i his Form is to ba cornpleYed and att�ched tothe Summ�3ry f-arm oFth��Jllnnesat&Pollutlon Control Al�encY's(MPCA}Compliance <br /> Inspectlon Form For Exlsting Subsur�aaa Sewege Treatmenit Systems. Observadons,Inberpr'e'fations,and con�lusfons mUst be <br /> completod by An inspector,rnaint�lner,or servicA provider. Completcd form must be submitted tn the local unik af governmpntwi#h'�n <br /> 1 S days. <br /> Prnperty owner name(s); Mer9�'et V�!�ge"1�� - -""- ' <br /> Property saddress; 2815 deer RUI1 Trall lAng L�►ke, MN 5�386 ,__ , <br /> Propefky ownet's addrass(iidlPPcrent�, ,.� _ ._._ _.. ..,.- <br /> Ca���{y; I�e�nepin . Propertyawnerphone' 952��9-6453 _ <br /> I hereby cenffy tha[J persorJslry rnatle!h�observaCions.lnterpr�tefrons, arrd canclu8lons repoYt2d on this farm and tha�they are <br /> e�rrect, <br /> NamR: �J+�me9 Braepelmann . _.. _ CeTtficatlan number: �_�. <br /> Business Ilcense name�nd numbeY: ��mcr J.Peterson Ca• Liceng�21 g __ Qr <br /> Name o�f local u vemment; _ --- --- -'-" <br /> D�Q: 3�11/11 _� <br /> 5ignature; . _ •— �" <br /> www.pcas� . n-��5 • 651-79fi-6309 � &00•b57-3864 • TTIf G51•28)-5332�r 900•65y38bd • AvailAUlP in alCprnaCive lorma� <br /> yviG-wwfsts�t-31 , 41�4/09 Pqoa�of 8 <br />