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68/19/2011 13:55 9528733112 PAGE 03/95 <br /> Parcel number: `^ _� System status: rnpliant ❑ Noncompliant <br /> (as determin�form) <br /> Tank Integrity and Safely Compliance <br /> tompliance Issue # of ' <br /> Date of cbs�rvation_ �I Reason fn�observation: _r. <br /> This form expires on(three yea�s): L <br /> ----•.---- <br /> Compliance questions/criteria: (Required) Vet'ification Method": (Optiona�) <br /> �Check fhe a ro �afe box (Check the appropriate box) <br /> Does the system consist of a seepage pit', ❑Y�s �lo ❑ Probed tank bottom <br /> cess ool d ell,or leachin it? � � <br /> Do any sewage tank(s)leak below their ❑Yes No ❑ Observed low liquid level <br /> designed ope�atinq de th� ? _ � amined construction records <br /> If yes,ideMify which sewage Examined emply(pumped)tank <br /> tank leaks. � Probed outside tank for"black soil^ <br /> Any'yes"answer!ndlcafes that the sysfem!s falling!o profect <br /> ground water. • ❑ PfesSure/vaCuurn Check <br /> ❑ Other. <br /> ' Seepage pits meeting 7080.2550 may be complient iF allowed "w <br /> in ordinance by local permitting authority. <br /> "*No standard prorocof exists. This/isf is no�exhausfive, �n <br /> sequanflal order, rror does!f indica�e which combinations <br /> ere necessary to make thrs deferminatian. <br /> Safety Check � <br /> 1. Are any maintenance hol�covers damaged,Cracked,or appe8red to be structu�ally unsound9 ❑ Yes" �lo <br /> Z. �Nere all maintenance hole covers�placed In a sec�red manner(e.g.,al1 screws replaced)? �es Q No' <br /> 3, Was secondary access restraint present(safely pan,second cover,o�safety netting)—highly recommended. ❑ Yes �lo <br /> 4. Was any other safety/heatth issue presant7 . ❑ Yes' �No � <br /> Explain: <br /> 'System is an imminent thr+eaf i'o publlc health and safery. <br /> Certification <br /> This form is to be completed and aitached bo the Summary Form of the Minnesota Pollutlon Control Agency's(MPCA)Cornpliance <br /> Inspection Form for Existing Subsurfsce Sewage Treatment Systems.Observations,inlerp�etetions, and conclusians must be <br /> completed by an Inspecto�, maintalner,or servfce provider. Gompleted form must be subm�tted to the�ocal unit of governmant within <br /> 15 days. �^ <br /> C <br /> Property owner n8me(s : __. ____ <br /> Property add�ess; � r_ _ _ <br /> Property owner' address pl diiferent): <br /> � <br /> CouMy� __ Phone: _. <br /> I hereby certify th�t I personslly made the observations, lnteipretations, and conc�usions reported on this Fvrm and that rhey are <br /> correcf. � <br /> Name; ��(�,�j, � J.�P�ll V Certification number: �(p�__ _______ <br /> 6usiness license name and number: ri�,�� _ ___. .. , o� <br /> Name oi local uni overn nt: <br /> Signature: Date: <br /> wq-wwisCs4- Compliance lnspect on Form jor Exisiing SS7'S <br />