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Sep 02 09 48:1� Joesph Oleon 7634988290 p.4 <br /> Parcel number: _, System status: �Compliant ❑Noncompliant <br /> (as dete�rned by this lo�m) <br /> Tank Integrity and Safety Cvmplia�ce <br /> tampt9ance Issue #2 of 4 <br /> Dale of observation: 8/28/09 Reason fior obse�vatbon: �yty Trar�sfer _ __,_,.,,, <br /> 7his fo�m expires on('Mree year5): ._8128/12 �.�.�v.. <br /> Compliance questionslcriteria: (Required) Verlfi�ation Mothod"`: (Optional) <br /> ...._._�Chedc tha epD��et�box)..... ..___._ (CheCk 1he appropriale boot) <br /> Does the system consis!of�seepage pir', I ❑Yes � No [� p�d���m <br /> cesSDool,drYwell,or lead�ingpit? I <br /> Do any sewage tank(s)leak befow their i ❑Yes � No � Obseroed Ivw Iiquid lev�el <br /> aesi�ned o��m�aer�n� �---..`.....__ � Examinod ounstrudion records <br /> tf yes,ideMily which sewage Q Examirted empty(pump�)tank <br /> �����• -.._...- ❑ Probed outsida tank for'61ack soiP <br /> Any"'jres"aaswer indicaLes that ihe aystera)s faplrig to pantect <br /> ��d� 0 Pressure/vacuum eheck <br /> ' S�P�3a P�s meeting 7080.2550 may be compqa�l if a�lawed ❑ Olt�er. PeDerson GomDan rL_ <br /> in oldinanoe by local pelm�tting authoritp. �._....r-�.. ,...�.,�_.__ <br /> "rVo sfandard p/nCOCor eX1Sts. 7Ais 4st is aof eXhee�stlue.in <br /> S9queAfiB/O/CI9/,nOr dOBS i�indiG�2f9�vhTCh COmbinStfOns <br /> ar+9 ne�cessery to mdc�this dei�armina�. <br /> Safety Check <br /> 1. Ar�e any maiMena�ce�ole coyers dameged.cracked,or appeared to be stn�cturaly unsourtd? ❑Yes' �No <br /> 2. Were aA mair�nante hole r.overs neplao�d io a sewred maan@r(e.g.,aIl scr�av,rs replac�ed)? �Yes ❑No' <br /> 3. Was secontlary aooess�straint present(safoq►pan,second cover,or s�fiety nelting)-ta8hly reoomrnended. �J Yes �No <br /> +�. Was any atAet safelylhealth issue pt+e5enrl ❑Yes' �Np <br /> Explain: � �.� <br /> 'System is an immineni threat t+�pvbflC healdr arrd sa�ety. <br /> Ce�tification <br /> 7his form is to be comPl�ed and aveched to the Summary Form of ttre Minnesota Pollution Control Agenc�s(MPGA)Con�plianoe <br /> Inspection Fcrt�n for Exfeting Subsurtace Sewage 7reatr+sent Sysben��.Obsarvations,i�terpretatbns.and oonclusions rt'�t be <br /> completad Dy an inspector,maintainer,or service p�vider. Comphtod torm must be submit�ed Lo the toc�l urrt of govemment witlrin <br /> 15 days. <br /> PropeRy oMmel'nsme(s): Tpdd&Amy Harfman ,�r,,��Y_,� <br /> Propgfly addf+eSS: 60 MYftlewOod RO�d,._OrOr►O_,,MN 55391 <br /> Property owne�s address(�f ditCerer�: <br /> CovrKy: Herv�egin , Ph�e: 6�2�51&2291 ........,,.,._,_..._.........._..�� _.._ <br /> ,he►eey c�y�t 1 pe�r,arry made the obsaN�;�m�r�a� �a��s�orted or,sn�rorm ar,a tr�r u�ey e,e <br /> �t <br /> Narne: Joseph d.O�on .��._..,,.�........,�..._ Certification rwrnber. 1255 <br /> Busir�ess lioense name end nurnbar. Rusty Olson's soi!and pe�culation testing Li��/810 .._ __�._.�_...,. or <br /> Name of bcal un' govemme�� C' of Orono <br /> �_..._... ..._— —••----•--...._..-•-----...._ <br /> �gnatu�e: Date: 8l01f09��,,..Y,�_...� .. <br /> wp-ww�stsl-31 tompfiara:e/nspectior�Form ror Existing SSTS <br /> 4/4108 <br />