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04/27/2919 21:26 7634975011 SPTESTINGINC PAGE 07169 <br /> , , , ', , <br /> Pa�el numbec „ ,. Syatem shWa: �ComplaM (]Nonaompliant <br /> (es dsfmmrinod Ay fhJs form) <br /> Tank IntegrNy and SaFety Gom�#lianea�Compliance/nspecNon Form fai Exisfin�BSTS <br /> Confpl9ante Issue #Z of 4 <br /> Date oi ot�servAUon: 4l16/10 �,� Reacon for obsenatlon; Request of Owner _ W <br /> Thia farm expirea on(thnce years�: M15/'10 _ _ _ _ <br /> -�.,.� <br /> Compllaece qua�tlonalaMterla:(aequlred) Verlflaaqo�M�thod'":�optionaQ <br /> rcneok a►o aapro�rt�te d ox (c+�N►R e,oAroprraf�nox) <br /> Does We syetem oon�lsi of a seepage p�C, ❑Yo� �No ❑ pr,pp��k��rn <br /> ceae ol d II or leaahl ft? <br /> Do any sewago mnk(s)leek bel�rv the�r p Yoo � oN ❑ Observed law Ilquld Ievel <br /> doai�nod opareUn�de�th? _. .,, ,.,M Q �xa�t�dned con�uuaion�corda <br /> I�yas,Id9nliy whlch � bcamined emp4y(pun�pet�tank <br /> sewago lank lo¢ks. <br /> Any'yre.s".r�swsrMd�c�ea d►ar�ho systan�s hrt�n�ro prore�� ❑ proa�w oute�w ronK�br Naedc soll' <br /> groand x�rsr. ❑ Pressurelvacuum chgak <br /> " Seepage��is meating i080.zaoo ma„��p��a�uo�d C7 otner. � ,�� <br /> in arofnanoo by local pertMRlns aulhorHy. ._,,,..,,� <br /> "Aro sts�darpprolb�cl e�lets.7rfs llstls►Iora�ua�e,M <br /> aoquenifel order,nordoes It lnc�cate xfiid►eombhl9Efohs <br /> ara nsossss►y Oo meke drla dleb�mina(ion. <br /> Safety Check <br /> 1, Ar�maintenano�hote cover��me�d,cra�ced,or appas�d a bo strualu�aly uneound9 �Yen• 0 No <br /> 2, 1Naro rt�mintenance hole wve�s repleaed in P eewred mannar(ag.,scx+ew�roplaoe�� �Yea p Noy <br /> 3. W�a aecontlary ecosss restrak�t present(oofoly�n,socond covsr,or Eaf�V neUlnp)—htahti reoormnandad. p r� ❑No <br /> 4. Ar�e othet safelylfle�a�h Issu�preaen!? Ll Yes' �I No <br /> 6cplaln: On M15HO�EImer J,peterson Co.repleced conorete oover on&ft ststlon, <br /> �� - � �� � .iY� <br /> *System l�on imrMnsrrt tlNsat to pnbNc M�alCN end BafMiy. <br /> Certiflcation <br /> Thia form is io be aomplatsd�nd atlachad b�1e Summa�ry Form of Ihe Mlnnesota Pollullon Conhd Ape�tay'a(MPCA)Compnqnae <br /> InapaeLon Fortn for Ezistlnp Subsu�fnco eew�go T�atnwn!9ystemr.ODaervaUons,fnMrpretatiana,and oafok��iona rnusi be <br /> completed by an Inapecto�,maiMsin�or servke�vvlder.C�mpletad form mu�t be wbmlind w the Ixal u�R o�yovemm�rt wltAin <br /> 19 days. � <br /> Propertyr arHner nart�e(F): Bnb Hardln ...� <br /> Prvperty address: Z295 4onpview Circle, lon�Leke,NAV 5fl8S8 .- - -.�_� .. <br /> wropady�wner'a address��r d�Rerent>; _,»` <br /> Cauniy; iiennep�n - proparty owner phone• 480-773�3945 '� <br /> I hereby ceMry�hat I personady made the observatJonr,pf�faf�ons,and ooncJua�bna rapo/!ed on this Portn and lhr�they ar� <br /> raa►Ieo' <br /> Neme; James Sraagelrtr�nn Certlticatlon numbor� <br /> Builnass Ilcense name and�umber, �Imo�J.Pate�aon Co, llcense#219 q. <br /> Nsma of bcal u i , v¢mment: + <br /> 3lpnetune: � .,... Dp�: 4121l10 ., <br /> www.prr�:etete. .u� • 641•296�6300 . Ba0-e49.9861 TTY A51-282•�332 or 6pp-657-986d . Avxllablr in altemntMc forn�ae <br /> wq�wlMsts•/•31 . �l i�/04 Poge 3 of 6 <br /> � i� •:��ra /.t T./.?[.6£9 L 00 �OSZt���a I.' ��I3 Wd T E:to o i o z•�z•��r <br />