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___ 04/15/2010 11:58 763498829�0 RUSTYS PERC TESTING PAGE 02 / <br /> "' V <br /> ` M���esota Po���x�o� Compliance Inspection Form <br /> . Control Agency <br /> 520 Lafayette Road North �Xlstl� �ubsu�aC� 8�wa9! Treat111�et Syste�ns (SSTS) <br /> sc.paui,nnN ss�ss-a�a4 Instrudions on page 7 <br /> Parcc�ll number. 3111823120007 For Local Trecking Pucposes: <br /> System steWs: �CompiaM ❑NcnoomPliarit � � � _ i j * <br /> (based on aN COmp/la►►ce►�lrementa) i k <br /> . , <br /> Sum�nary For�n , <br /> Property Informat4an <br /> Properqr owner neme(s): Mk�eet&Rebecca Nelson " <br /> Property eddres�: 4280 Stxth Av�N. Orono MN�i.",3�W <br /> Properiy owr►er's address{d dMeron�: . � <br /> Cvurtty_ Hennepin Properly awner phone: Pertnitti�g aut��oRty_ City of Orono <br /> pete eys�bam oon�lruc�ed- 1 W16/00 Reeaon ior inspec�on: Property Tranafer <br /> System DescHption <br /> Approobrl►9t6ly 2-t000 gallOn eeaRfc tahlcs� 1-1000�allon lift Steibn and Approxfmaeely 380 aquere <br /> Brief sys�n deacripdon: iaet o(mound rodcbed• <br /> Lxal peimit number. ?298 Numbmr of bedrooi►es: 3 Desi�n 11aw rate: .83 <br /> Is ths sps�m: ' <br /> i�sno��r,d�� p v� {�r�o In WeNAeed Probedlor�Ar�i? ❑Ye$ �No <br /> An U.S.EnvironmenEel Pro�eciton 3yst�em serving a Minne'aa�DepertrneM <br /> A�en�y(EPA)CIeaB V inj�tlon Wd17 D Yes �P!o of Heath(MOFi)Iicenae�!fe�dlity? ❑Yes �No <br /> CompNahc� Ststus(easod on et�te►equiremeMs-aadnlone��xa�ro�irementa may e�so apply.) <br /> 6ased on the U�farrnerion g�thered and reporoad on�tt�ched forms.�te oompiianoe stetus af thi�sysUem Is(d�eck o�e): <br /> �Ceniticste of CompElerioe—vaffd until(3 yeers 1ran dat�of�epo►�: 4JBR013 <br /> ❑Notfce oT Nanmmpllence-Fcr Nonoompliar�t systs�r�s: <br /> The reasvn tor rwncan�la <br /> Thls non�ompllar�t�y�sm Is cla�itisd as ch�ek on�belaw): <br /> Q 1mmlr�M threat to{wbl�iieal�&safely �Falling ta prtited grvund wede� ❑Not in oomplianoe wlth operaiing permit <br /> C@f't1flCatI011(Completed torm mu8t be submhtad to fhs looal umt of govemmeM wllt�ln 1S dm�rs.) <br /> r ner�by oert�y u�ar ea the neaessa►y intwmetfvn has be�n gatheied ro determire the canp�Jenoe sralus af ri�is sysrem_nAo <br /> det�mtlnadon af ffuh�ie sy�tlem pe�ibrmenoe Aas besn rta cen be made du�e b unb►owr►c�a�d/do�►rrs duri►ry system oonstnecdon, <br /> po�saolblVe abuse of the system,!►radequaDs meli�onence,or fiRwe water usa�s. <br /> N.me: Joseph J.Oison C.erdflCaUon numbe� 1256 --- <br /> 8usiness liCense name 8rM numbec Rusty Ohon'a soil�d pe�a�le�fon�astln0 l-fc#�10 or <br /> Nems at bcal unit of goMemmen� C' of Orono - -- <br /> Signature: De�te: 4M 2/10 <br /> Required Attachments m�oo�com�ste:Th�s�nspect�o���Port k�pa9es�on�. <br /> Cheak compllAnCa fomw altached: �Hydraullc Perfortnenoe ❑Tank Intagrity �Shc Separatlon ❑OpereCing Pertnh Form(If <br /> appllcablo) ❑sYst�m a�winplAe-0uN[drawin0 O��af any loc4{requl�mbt�ks ttist are dlPferont lrom whet la requNed on thls <br /> fum �Soll 9orin6 tvas []Abaodanrt�r►t fomi(IF,aDPtopf9Y00),[]Ofher InTortn�dbn(Ibt): <br /> Upg�ads R�qutremsr�b fdrrlrsd hom A�nn.S1et§11�ss)M,lm�r�a+1 d►�est to p�Ye ne�m ano sa�b IniPHS)must as uyqoao�a,npuoia o► <br /> 1�1me dk�nmm�uad�Idn Aan mcntlrs d ncaMpf of UII�noNc1 Or WdNn e a11o�1erPe+lbd Nnq�drsd bY loo1V dQlMna�.R d►e ay�n At/e�p to p►oNCt O�ntl <br /> waf�r,Vw ayahm mu�ba uAD+ads��a�M�d or�a uas�wr0 wl�Nn tlhr EAn��rbed bY bcd or�lrrarroa 1f an axbw,v s�rn la not M�fnp es C�MMr�01n <br /> a,�,.nd n.a ar►e�u n«��r w o.sr�s�r��uo+,.e�,.,n►.�a.�n n..o na w u�,aaed,���a ns us�a�a�d��d,�►wrnv+�►r <br /> rocel adlneqoe d►et(s morr aDkt 7htr pvNmbn do�a not eAaY b aya�e M�Aohlsnd ers�s,W�d Protac�bn as�ar N►oa�usod M oo�nec6ra►�l,�bod <br /> p�y�rip�,N101oCp��D o�b�ananm es dMbied M Asw. <br /> wq-wwfsts�-3f � . Comp/tance Ins�attlon Form jor Existinq SSTS <br /> 4/4/OB <br /> , i � , ,a: <br />