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� � 06f28/2606 11:03 7634988290 RUSTYS PERC TESTING PAGE 64 <br /> � prbp�prrna�(s)seera Linde 5i�e Addre�: 214o salem C�d <br /> (P�.�e aresaNGe bhe sysi�m caam��r): <br /> What mathod�vrer+e used bo maloo tit�e�eneln�tlons ror th�oo�npllanca Insp�ion? (ll�:ll�st�noaidpo�n�co✓ezisi� <br /> The fia�Porv/ng//si'Is not arheusflv�nat in s�quenda/arAer no��wfikh cnvnb�iwbbr�s aie n�ry 1a make e dedenr►�abbn) <br /> Yy�Yht.�ok�) <br /> o Probed tank botfGom � Seardxd fw surfaoe oudet ■ Conduc�ed soil borings <br /> o Observed bw liquid kwei v Pertormed hydraulic test Depd�bo Iimi�ng lay� S'�.Q <br /> • bcamined const.reoords • Searched for seeping in yard Deptl�to system bottom�? , <br /> o Examined empty(pumpe�taek ■ Chedasd for badc up In home a 6camined reoords <br /> Cl prpbed out�lde tank f�or"bladc sal" o Ex�ve ponding in sdl sy5tem/D-boxas o LGU Umldn9 layer Ve�ficatlon <br /> O Pl�sure/vacuum thedc o Homeown�bestfmony 0 Othe�' <br /> o p� o Examined fi�svrging in tank <br /> 0 �B�C�C 50��~ab0'V@ 90I�Sy:#8111 <br /> 0 �1Cf <br /> �Btll�O�tilA�VS�111 — <br /> 9ased on the opmplianoe aiterfa,the sy�m stab��is: (check one) � faliing (to pr�tect groundwater) ❑ an <br /> immi►�ent threat Oo public hea�h or safehr(I1PHS), ❑ no�-aompliant(rnoniboring iSsue). ❑ canpliant(non-of the 3 <br /> previous condidons). Is tl�is s�bem a EPA Cl�ss V I�e�tion Well? O yes i no <br /> The�one�lhls dowment Is�: ❑ CertlflcaEe of Gompliance / Notloe vF Nonoompllanoe <br /> I hereby aertity as a sta�e of Minnesota liaensed Inspe�bor and/or Deslgner I or Qualified Employee Inspector and/or Qualified Empoyee <br /> Designer I tf�at I oondt�oed an Irwestlgadon t�hat aowra�y debermined the oompiianae status of this sy�em and tfiat m�r reaorded <br /> ob�vations are aacurabe as�this dafie. No determinadon of futute hydreulk perfnrmanoe has been rwr qn be made due fio <br /> unlmown aonditior�s du�ing sysbem aonstruction,abuse of the sysbern,inadequabe maintenarioe,or future water usege. <br /> Ir�ec3ors name(prir�t) ,�6] o�on, , Pho�:r,6���ws•8�T9 <br /> Liae�e and/or Registra�on Number, si0 ,.. Addr�s• <br /> ��Ipypd bY: ' Address: +�� Rh�er�w i��NE. Nanorer,MN.653�1 <br /> Signature Da�e: 6/2S/06 <br /> jdm►�dhnm M��§I15.5S) <br /> An mt�st be up�raded,nqoVeaed.ar l�,�di�nued witl�/n!an inarttlts of�t of drls nab�ar w�iir�e shovQAr ppnlad!f <br /> �qr�ive�o�hy bral ar�i�ariae If�e sy�tern fa�s tn pr�Pe�t�ta�d�+�rpunle�ian,daen b�i�e s�n must be�pg�aated <br /> �d,�r Rs ta�d�.rondnwed w�hM the t�e�+pu�d by ruAe ar the Aor.�l cvnm'vranae !f an ex/s�dn�.sy�m�s not failin�as a�linc�d/n <br /> �w,a/M/aas at�teast twn 16et a�o�qn s�oV/s�rabiany tli�ri�e sys�m r�n�['be�g/ao�d,�qoau�d.�P�d,o►r�s use <br /> da�aov�nued,►actiwi�i�d/n�,p any loral a�dnanae a�ar/s m�are s�7ct nNs ab�s nor sy�ary ta syst�►►�s m.sh�v�fand araas, w�d�ed <br /> peroie+c�ai a�ar tha�e u�ed in aov�criia�n wdlr fivo�d,b�ew�ag��d doa�g✓ng�mantr as a�i�d in/aw. <br /> 1) Slbe sl�e�bd+whkh indudes the s��em lacadon(mandatnry). Odter iGems eould Indude:well,well seffiaKic bo sysbem,dwelling or <br /> o�'bufldings,bnla(s),reseru�ed sal tt+eatrnent area,surfaae wabet a�soll borin�locadons. Indude as�ullt dnwing if evailabie. <br /> �) Sofl bot'in9 logs�showing eac��horimn. Indica6e tl�e textute,aota',redowmorphk fea4urs depth to bedrock,5bnding wa�er and <br /> whether the maberial is fill. <br /> 3) A Ilst of any and all roqulrements of the Iccal ordinance thaR are diRers�t from the sta�e requfremeM�ref�red to on this fam. <br /> 4) A homeowner survey of syseern peifnrmanoe.sl9ned by the hon�eo�vr�as being fectual. <br /> S) MonPooring data as approprlabe. <br /> Page 2 of Z <br />