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06/29/2006 23:19 7634988290 RUSTYS PERC TESTING PAGE 64 <br /> Property Owner(s) Ran �4n Site Add�ess: �160 S ssen Road <br /> Svsbem�irna�nenls(Ple�ase de�crib+e the system cnrnpov,enCs): <br /> I n xlm <br /> sausre�af trand�as oer citv r+eo�rd. <br /> What mathod�were used to make the determinations br the compflanae Inspectlon� (Note:No s�indard prol�rol Qx/sti <br /> ' 71�e�ing/lsr Is not e.r/�ataGNe, rwt in s�quentia/aoier naor�ndira�es whkh canb/na�ars ere�ary ro make a determinado�hj <br /> Watier�iaht tenk(s) Vertical Seaar�,tlon Disianc� <br /> o Prohed tank bot6om � Searthed For surface outlet m Conduded soil borings <br /> C] Obse►ved low liquid level ❑ Pe�fam►ed h,ydraulic test Depth to limltfng layer �.�' <br /> � Examined mnst ne4ords � Sea�hed for seeping in yard Depth ta sys�em battom j,Qj,� <br /> i 6omined empty(pumped)tank � Checked fo�back-up in home O Examined r8o�rds <br /> � Probed outside tank for"black soll" o Exce�lve ponding In soil system/D-boxes C] LGU l.lmlting Layer Verificabion <br /> O Pressure/vacuum check i� Homeovmer te5iimony o Other <br /> o Ott�er ❑ Examfned fnr surging in tank <br /> p "Black sofl"above soil system <br /> ❑ Other <br /> on tfie aompllanoe criberia,tl�e sysbem status is: (check one) ❑ failing (to protect groundwater) ❑ an <br /> i minent threat to publfc health or safety (1TPH5), � non�omplient(monitoring Issue). � compliant (non-of the 3 <br /> oo�ditions). Is thls systiem a EPA Cls�V I�ectlon Wall? O yes � no <br /> this document!s a: 'Certifica0e of Com iance 0 Notiae of Noncvm liance <br /> I oertify as a staCe of Minne9ola lioensed Inspec�or and/o�Designer I or Qualified Employee Inspector and/or Qualified Employee <br /> ner I tl�at I conduc�ed an irn�tigatlon that a�urately debermineO the eompllanoe�s of tfiis system and that my reoorded <br /> s are acarate as af thls dabe. No determination of future hy�drauli�perfo►mance has been nor can be made due to <br /> u oondifions duHng sys0em oon�ion,abuse of the syskem,lnadequabe malnbenanae,o�futu�e water usage. <br /> I s narne(pririt) �QS�I�h] 0190n Phone:1763]498-$779 <br /> and/or Reglstra�on Number�l� AddresS= 11481 Rlvervlew Road NE..Hanover.MN.55341 <br /> ployed by- ' Address: 11481 Riverview Road NE.,Hanover.MN._55341 <br /> nabu Date: 6/29/06 <br /> jdeiivtrd from Minniesl�ta Statutes-§X15.SS) <br /> A 17PHS must be upgraded, r�c�d, or its use discontinr�ed rvithin ten montfis of rac�ipt of Uiis nobce or wrthin a shwter peiio0 if <br /> u�+d by�4aca/orrl/nancae If die syst�m falls lt�Fvavide su�nt qrnunrJw�ter prot�c�ion, then dre system must be upgra�ed, <br /> ,cY iLs uste disrs�n�'nued wibhin tl�e lime repuirad by�u/e ar bhe/ara/Ord/nan� If an exls�ng syst�m is not failing as�fiirEd in <br /> !a ,and has at/aast twiv feiet of des�qn s�il s�rabov�, tllen�he system ne�d not de upgrad�d,�pair�d, replaaed, or ils us� <br /> tinuer/,nolwi�h.s�rldi»g any lara/adinanc�that ls more sbict. Th�Cs dc�s noot app�ly to sys�ns/n srio�/an0 a�as, w�ell%a0 <br /> � a�s,or those as�d in cvnne�ction wit�"��ad, beverage, and lodging establis�hmenls as def�ned/n/aw. <br /> 1) Slke sketch which includes the system Ivcation(mandatory). Other items could fnclude: well, wetl setback to system,dwelling or <br /> olher buildings,tank(s), reserved soll treatment area,surface water and soil boring locations. Include as-built d�awing if available. <br /> 2) Soil boring logs,showing eadi horizon. Indicatie the b�cture,mlor,redoximorphfc features depth to hedrock, standing water and <br /> whether the meberial Is HII. <br /> 3) A Iist of any and all requirements of the locai ordlnanoe tliat are different from the state requirements referred to on [hls form_ <br /> 4) A homeowner survey of syst�em perFormance, signed by the homevwner as being Factual. <br /> S) MoniCoring data as appropriat�e. <br /> PageZof2 <br />