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09/30/2010 01:02 7634975011 SPTESTINGINC PAGE 05111 Parcel number. — System status:. N Compliant ❑Noncompllsnt (as determined by this fort) Hydlraulle Performance and Other COMPIllanee — Compliance Inspection Form for Oxisting SSTS Compliance Issue #1 of 4 Date of observation: Reason for observation. This form expires upon next inspection or in three years,whichever occurs first; — "— Compliance qulestion4/criterial: (Required) Verification Method*: (Optional) ....,—(Chi ox) _ Does the system discharge sewage to the ❑Yes �No (C/rerk the appropriate box) „ground surface? _ I'Searched for surface outlet NQ Does the system discharge sewage to drain ❑Yes ❑ No ❑ Performed hydraulic test Tile or surface waters? ® Searched for seeping In yard u0 Does the system cause sewage backup ❑Yes No ❑ Checked for backup In home into dwelling or establishment? _ Excessive ponding in soil system/D-boxes go Do other situations exist that have the ❑Yes ®No Potential to Immediately and adversely ❑ Homeowner testimony Impact or threaten public health or safety Examined for surging In tank _,(electrical,.unsafe covers etc. ?,_ Any"yes"answer indkates that the system is an—Imminent � "Slack soil"above still dispersal system Mo threat to pubiic health and sorely, ❑ System requires"emergency"pumping ❑ Performed dye test Does the system pose a threat to ground ❑Yes in No water for any conditions deemed non- ❑ Other, _ _.P-rolective as determined by the inspector? "Yes"indicates that the system is failing to protect ground water.If"yes, describe the condition noted: _ .— "No standard protocol exists. this list is not exhaustive, -' -- — in sequentlal order,nor does it indioole which —_. , •, __ combinations are necessary to make this determination, Certification This form Is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compliance Inspection Form for Existing Subsurface Sewage Treatment Systems.Observations,Interpretations,and conclusions must be completed by an inspector.Completed form must be submitted to the local unit of government within IS days. Property owner name(s): %•1'�r/hr`7rM Property address: �� (•�.aaL��,��L, t � Property owner's address(If different); County: Ja i ) Property owner phone: I hereby cerilly that 1 personalty made the observations, Interpretations, and conclusions reported on this form and that they are correct Name: Certification number: b;a 0 _ Business license name and number. 5 'P-f i►,a t�� 111 C , 111t„kt-, *1-4 f k) N' Lel w!.(wci � ?or Name of local unit of 7oefnment* • —/-1._... Signature: _ .__. ........ Date: _ 9.,_- Z5 www,pca.state.mn.us ..,. • 651.296-6300 000-657.3864 TTY 651-282-5332 or 800-657-3064T.� wq•wwistwi-31 • 4124109 Available In alterative formats Page 2 of 8