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May 171011:00a 763-213-0695 p.3 Parcel number: I-15P O cry Le t'JA..«va..iP.Ad`-- S3�y t status: lel Compliant 0 Noncompliant (as determined by this form) Tank integrity and Safety Compliance Compliance Issue #2 of 4 Date of observation: 5— )3 —/6 Reason for observation: ' This form expires on(three years): Compliance questions/criteria: (Required) Verification Method'.: (Optional) (Check the appropriate box) (Check the appropriate box) Does the system consist of a seepage pit", 0 Yes l}yJ No lac, Probed tank bottom cesspool, drywell, or leaching pit? Do any sewage tank(s)leak below their RI Observed low liquid level ❑Yes 0 No designed operating depth? K Examined construction records If yes,identify which sewage 0 Examined empty(pumped)tank tank leaks. ( ( P-obed outside lank for"black soil" Any"yes"answer Indicates that the system Is failing to protect ground water. 0 Pressure/vacuum check ' Seepage pits meeting 7080.2550 may be compliant if allowed ❑ Other: in ordinance by local permitting authority. ""No standard protocol exists. This list is not exhaustive,in sequential order, nor does it indicate which combinations are necessary to make this determination_ Safety Check 1. Are any maintenance hole covers damaged,cracked,or appeared to be structurally unsound? ❑Yes" 6i1 No 2. Were al maintenance hole covers replaced in a secured manner(e.g.,all screws replaced)? NE Yes ❑No' 3. Was secondary access restraint present(safety pan, second cover, or safely netting)—highly recommended. ❑ Yes RINo 4. Was any other safety/health issue present? ❑Yes' KNo Explain: ''System is an imminent threat to public health and safety. Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compliance Inspection Form for Existing Subsurface Sewage Treatment Systems. Observations, interpretations, and conclusions must be completed by an inspector, maintainer, or service provider, Completed form must be submitted to the local unit of government within 15 days. Property owner name(s): _ ,p Property address: 96-0 t cp- ..0.-4.-1- _ Property owner's address(it different): // G � County: _ to— Phone: / " f - / - (337 I hereby certify that I personally made the observeticns, interpretations, and conclusions reported on this form and that they are correct. Name: .0A. _ Certification number: 2_4 3•" — 3 Business license name and number: R— b-' 73 or Name of local unit of government: Signature: ct,,cs&e... ev_____11.416i _ Date _ I —fb wq-wwists4-31 Compliance Inspection Form for Existing SSTS 4/1/08