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OCT. 22. 2009 2:27PM Edina Realty Wayzata-RR3 N0, 3565 P, 5 <br /> , . <br /> Parcel nu ber. ` System status: pmpliant ❑ Noncompliant <br /> (as detem►ined y t Is foim� <br /> Tank Integri�;,r and Safety Con�pliance <br /> Compliance Issue #2 of 4 � <br /> Date of vh�servation: q�34—V \ Reason for observation: �yl�� <br /> This fomt expires on(three years): <br /> Compliance questions/criteria: (Required) Ve�i�cation Method*": (Optional) <br /> _ (Check the app�� riate box (Check the appropdate box) <br /> Does the system cor sist of a seepags pit', ❑Yes �No ❑ Probed tank bottom <br /> cesspool,drywell,or leachin it? <br /> Do any se�vage tank s)leak below thelr ❑Yes No ❑ Observed low liquid level <br /> de9'.ned o eratin c� ? Exsmi�ed construction records <br /> If yes,ide ' which �ewage Examined emply(pumped)tank <br /> tank leaks ❑ Probed outside tank for"black soil" <br /> Any`qes"a�swer in�licates that the syst�em!s fa111ng to protect <br /> ground ter. � ❑ Pressure/vacuum check <br /> ❑ Other. <br /> ' Seepag pits meef r�g 7060.2550 may be Compliant if allowed <br /> in ordin nce by loc�I peRnitt(ng authority. <br /> "No standard profnco/exist�. ThIs list is not exhaustive,in <br /> sequentia/order,nor does it indlcate which combinatlons <br /> are necessary to meke this determinatlon. <br /> Safety Check <br /> 1, Are any maintena nce hole covsrs damaged,cracked,or appgared to be structurally unsound? ❑Yes' [�lo <br /> 2. Were all mainten;ince hole oovers replaced in a secured manner(e.g.,all screws replaced)? Yes � No" <br /> 3. was secondary a:cess restraint preserrt(safety pan,second cover,or safsty nstting)—highly�ecommended. Yes �,No <br /> 4. Was�ny other sa'ety/healih issue present? ❑ Yes' �No <br /> Explain: <br /> •Systoem Is an ir�minent threat!o public healfh and safety. �� <br /> Certification <br /> . •. ��h�..� . <br /> 7his fvrm is to be con ipleted and attached to the Summary Form of the Minnesota Pollution Control Agency's jl�1PCA)Complfance <br /> Inspectlon Fonn for Existing Subsurtace Sewage Treatment System�.Observations,interpretations,and conclusions must be <br /> completed by an insp 3ctor,maintainer�or serv(ce provider.Completed form must be submitted to the Iocal unit of govemment within <br /> 15 days. <br /> Property owner name;s�: � T S <br /> Properry address: J F 1� �} <br /> Property owners address(Pf differenc): <br /> County: __���� Phone: . <br /> 1 hereby certi/y U�at 1 E�ersonally made the observations, interpreta�ions, and conclusions repoRed on this form and that they are <br /> correot ' <br /> Name; �f� �a�U� Certification number: �Z1�D�� <br /> Business iicense nam 3 and number: 5U]�I�LU� Sp,�^Uj(�� ((1C, �� � orN . <br /> N�me of locel unit 16vem <br /> signature: Date: 3d'd _ <br /> wC-wwisCs4-31 (.mm�linnro Incnartinn Fnrm fnr Frietinn fC7"� <br />