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Parcel number: _ System status: Compliant ❑ Noncompliant <br /> (as determinedyr> is form) <br /> Tank Integrity and Safety Compliance <br /> Compliance Issue #2f 4 <br /> Date of observation; I1d'� p. Reason for observation: Ski, <br /> This form expires on(three years): <br /> Compliance questions/criteria: (Required) Verification Method'": (Optional) <br /> (Check the appropribox ox <br /> — (Check the appropriate box) <br /> Does the system consist of a seepage pit', 0 Yes `n No robed tank bottom <br /> cesspool,drywell,or leachin• •it? <br /> Do any sewage tank(s)leak below their 0 Yes No <br /> 0 Observed low liquid level <br /> desIqned operating depth? Examined construction records <br /> If yes,identify which sewage Examined empty(pumped)tank ozdvei <br /> tank leaks, <br /> 0 Probed outside tank for"black soil' <br /> Any"yes"answer indicates that the system/s falling to protect <br /> ground water. • 0 Pressure/vacuum check <br /> • Seepage pits meeting 7080.2550 may be compliant if allowed <br /> CI Other <br /> in ordinance by local permitting authority. <br /> "No standard protocol exists. This list is not exhaustive,in <br /> sequential order,nor does it indicate which combinations <br /> are necessary to make this determination. <br /> Safety Check <br /> 1. Are any maintenance hole covers damaged,cracked,or appeared to be structurally unsound? 0 Yes' *o <br /> 2. Were all maintenance hole covers replaced in a secured manner(e.g., all screws replaced)? $Yes ❑No' <br /> 3. Was secondary access restraint present(safety can,second cover,or safety netting)-highly recommended. 0 Yes o <br /> 4. Was any other safety/health issue present? 0 Yes' No <br /> Explain: <br /> *System is an imminent threat to public health and safety. <br /> Certification <br /> This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's (MPCA) Compliance <br /> Inspection Form for Existing Subsurface Sewage Treatment Systems.Observations,interpretations,and conclusions must be <br /> completed by an inspector,maintainer,or service provider. Completed form must be submitted to the local unit of government within <br /> 15 days. <br /> Property owner name(s): fJi�' /i _ <br /> Property address: , 4# `I Mil/ t iA,/ < S ,14` <br /> r <br /> Property owner's address(it different); _,_.• <br /> County: Aidniirl_ Phone: _.,.._..... <br /> t hereby certify that l personally made the observations, interpretations, and conclusions reported on this form and that they are <br /> correct. (� <br /> Name: C@N - ki��3(� _ Certification number Rk 659_ <br /> Business license name - • number: —4114 ♦ Ser„i?.tS IrG. asoa or <br /> Name of local unit off. ernme- : <br /> Signature: ' i� Date: J n <br /> ,?,7 ._ <br /> wq-wwists4-31 Compliance Inspection Form for Existing SSTS <br /> 4/1/08 <br /> 50/Z0 3910d ZTT££L8ZE6 ZO:ET ZTOZ/£Z/£0 <br />