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Mar 21 12 p4; p 763-213-0695 p.3 <br /> i. <br /> � <br /> • Pr I a ress: �O J � .�0�,�,�- Inspector initialslDete: � "1���� �� <br /> 4. S il eparation—Compliance comAonent#4 of 5 <br /> C� f installation: ' ❑ Unknown Verification method(s): <br /> s�w ndNYeUhead protectioNFood Be�erage (�Yes ❑No 5oi!observation a�oes rrot expire. P►�evious soi! <br /> �'!�� � obsenraBons by tw�o indepe�ent panies are suf�rcienG <br /> o liance criteria: unless site conditions have been altered or local <br /> �quirements dilfer. <br /> or ms built prior to Apri!1, �996, an�d Q Yes ❑ No <br /> t I ated�n Siro�laad or Wellhead � Conducted soil observation(s)(Altad�boring logs) <br /> f� ion Anea or not serving a foa1, ❑ Twa previaus verifications(Attach boRng logs� <br /> 61eve ge orlodging establishmenC • <br /> ❑ Noi applicable(HaJdng lank(s),no drainfie� <br /> rai Id has at IeasE a twafoot vertical ❑ Unable to verify(See Camrt�ntsiExplanation) <br /> s pa 'on distance from periodically <br /> s d soil or bedrock. ❑ Other(See Comments/Ex�anaaor�) <br /> o rformance sys[ems 6u+Jt April i, �Yes ❑ No Comments/ExpJanafian: <br /> 1 9 rlaterorfornon-pe�fwrnance <br /> sy s located in Shor�eland or We!lhead <br /> Pro�t 'on Ar�sas or serving a food, <br /> bleve e, orbdging estaWishmenk <br /> rai Id has a three-ioot verlical <br /> s pa ' n dstance from periodically <br /> s tu sal or bedrodc' <br /> �x 'menta�', `Otner, or °Perfo�mance' �Yes ❑No Ind"icate de ths of elevations <br /> s buil�under pre-2008 Rufes;Type!V . �� <br /> �V tems built under2008 Rufes(7080.' R. Bottom of dislr�upon media <br /> 2�3 7080.2400 (Advanced Inspector <br /> required) B. Penodicall salureted soil/badrock <br /> rai Id meets the designed verlical ' '��, � <br /> s pa tion distence from periodically C. tem s ara6on ' <br /> siatu d soil or bedrodc. ! �� <br /> D. R uired com liaoce se arad�n" �F� <br /> `RO"aRSW@f'e1LIOV6 J/1dCat@.S�I@ SySf@I11 IS •�y be reduced up to 15 percent if allowed by Local <br /> ail to Protect Gror�naM+ster. Ordinanae. <br /> 5. p cltin� Perntit �nd Nlt1'ogel� BMP'"—Compliance component#5 of 5 �Not applicable <br /> fhe m operated under an Operating Permit? �Yes ❑No It"yes",A below is required <br /> s Rhe m required to employ a Nitrogen BMP? ❑Yes ❑ No If"yes", B below is required <br /> ' B P�Best Managerrtent Practice(s)specaifred in fhe system design <br /> e nswer to both que�ons is "no;this secfion does nof need to be compleiBd. <br /> m iance criter�a <br /> rating Rermit number. <br /> ve ihe O eratin Permit r uirements been met? �Yes ❑No <br /> I the re uired n' en SMP in lace and erl functioni ? Yes No <br /> y o"answer Indicates Noncompliarrce. <br /> rs Requieements(Minn.Stat§115.5�An im�nt�at to p�b6c hea�th and saf�ty(1TPHS)must be upgradad,rapfaced, orlts nse <br /> widlun ferr rr�a�lhs of receipf of N�is noGce or wrlha+a shorter penod ifrequined by loc�!o�inan�.!f tlte syatem is faMng to protect <br /> und ater,the sysfem mvsl be upgraded,repfeced,orits use dlscontinued within the trme requlred by focal ordinance.lfan exiating aystem <br /> ot f n�es ded'med b►law,and hes af least twv fest of�sign soi!separntion,then the syst�m need not be uppQr�deal,rtspal�d,replaced,or <br /> �wnue�d,.,onvrmsrandiny arry rocer wwnance rnar is more safcr. mis provisrvn does nor appry m s�srernns in srrare�ana areas, <br /> h PmtedMn Areas,or those us�ed in coruierxfon wlfh tood,beverage,arrd lodging estaWi'shments as afefined in lew. <br /> www .mn.us • 651•296-6300 • 800-657•3864 • TTY 651-282-5332 or 800-657-3864 • Available in altematfve foRnats <br />