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07/17/2008 04:23 7634975011 SPTESTINGINC PAGE 64/99 <br /> Parcel number. _ System status: �Compliant ❑1Vancompllant <br /> (as dete►mined by thls form) <br /> Nydraul�c PerFo�rma�nce �nd Other Complian <br /> Compliance Issue #1 of 4 <br /> Date of observakion: 7�al--p��� Reason fo�observatio : �pQ.pQ <br /> This fonrt expires upoh next inspection or in fhre�years,whichever occurs first;����5�� � <br /> �� <br /> Compllance questdol�s/crltena: (Requlred) Verific�tfon IlAethod": (Oplional) �^ <br /> ,_(Chec/c the appmprlat�e box) � (Chack the appropriate box) <br /> Does the system discharge sewage to th� ❑Yes (�No <br /> ground SurfAce? ❑ Searched for surface oudet <br /> Does ihe system discl�arge sewage to drain� ❑Yes �No 0 pe��ed hydreulic test <br /> lile or surFece waters? � Searched for seeping in yard .q.1a <br /> Does lhe system c�uae sewage backup ❑Yes �Nv C1 Chedced for badcup in home <br /> _into dwelling or establi,sliment? <br /> I� Excasaive ponding In aoil systeM/D-boxes� <br /> Do oiher situa�ons exlst that have the ❑Yes �No <br /> . potenUsl to Immedl�tely�nd edtrersely ❑ Homeowner 1esBmony <br /> impact or threaten publlc health or safety ❑ �camined for surging in tank <br /> 1electrical,unsafe covers,etc. ? <br /> Any"y+�s"answQr►ndk�tes thRt the system!s an imminent � � 'Black soil°above soil dlspersal system N,p <br /> threat to public hpalth andsatety: ❑ System requfres"emergency pumping <br /> ❑ Petformed dye test <br /> Does the system pose a threat to ground ❑Yes � Nv � <br /> water For any condit�ons deemed non- � Other. <br /> prote"ctive es determined b the ins ecEor? ' <br /> "Yes"indlcafas t`hat the system�s failing(�o protect � <br /> ground water.If"yes; describe�e conditfon noted: - .^ <br /> � "No sfandeni protoca!exists. This/isfls not oxhaustive, <br /> ' in sequontie!oMer,nor does!t indicafe whlch <br /> .. __ .� combineNons�ne necessary to make thls determinahon. <br /> [ertificetion <br /> This for►n fs to be completed and ettached to the Summary Fortn of e Minnesota Polludon Control Agency's(MPCA)Compiiance <br /> Inspectlon Form for Exfsting Subsurtaco SeWvago Treatmerrt 5y ms.Observations,InterpretaUons,and con�lusions mi�at be <br /> completed by an inspector.Compl�ted form must be submltted to tf� local unit of govemment within 15 days. <br /> Property owner name(s): ,b.{��„j �'���c� <br /> Property address: ���-4�, ,LO,��- � ,,. �� -- <br /> Property owners address(if dlF�eren�: � <br /> County: � Phone: ��� .?p0� . � <br /> 1 hereby certfty th�t!per.sonally made fhe observAt/ons, interpnetatio , and conduslons reported on fhls foim and that they er� <br /> correct � <br /> Name: ���, ��(���y��� Certification number. ro e?,7 <br /> 8usiness Ilcensa neme��d number: ��` � � �� �►_rl�-� �?��� � _ ��� �� <br /> Name of local unit of gwemment: � <br /> Slgnature: �G a � ' <br /> ��—� Date: �—g�Q _ , . <br /> wq-wwists4-31 <br /> 4l�los Compliance InspecPion Form for Exfsting SSTS <br />