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Property Owners) /ti�5 Fire No./ Parcel No. .................................................................................................... System Components (Please describe the syst components and attach site sketch showing system location): 0 What methods were used to make the determinations for the compliance insp , ion? (Note:No standard protocol exists The following list is not exhaustive, or in sequential order nor indicates which combinations may necessary to make a determination) Watertight tank(s) Hydraulic Functioning Vertical Separation Distance ❑ Probed tank bottom K Searched for surface outlet ,� Conducted soil borings ❑ Observed low liquid level ❑ Performed hydraulic test Depth to limiting layer 3z- V, Examined const. records 1i_ Searched for seeping in yard Depth to system bottom ❑ Examined empty(pumped)tank ❑ Checked for back-up in home Examined records ❑ Probed outside tank for"black soil" ❑ Excessive ponding in soil system/D-boxes ❑ LGU Limiting Layer Verification ❑ Pressure/vacuum check ❑ Homeowner testimony ❑ Other ❑ Other ❑ Examined for surging in tank ❑ "Black soil"above soil system ❑ Other Status of the system Based on the compliance criteria, the system status is: (check one) ❑ failing (to protect groundwater) ❑ an imminent threat to public health or safety (ITPHS), ❑ non-compliant(monitoring issue) Rrcompliant(none of the 3 previous conditions). Therefore, this document is a: P(Certificate of Compliance ❑ Notice of Noncompliance Is this system an EPA Class V Injection Well? ❑ yes ❑ no Certification I hereby certify as a state of Minnesota licensed Inspector and/or Designer I or Qualified Employee Inspector and/or Qualified Employee Designer I that I conducted an investigation that accurately determined the compliance status of this system and that my recorded observations are accurate as of this date. No determination of future hydraulic performance has been nor can be made due to unknown conditions during system construction, abuse of the system, inadequate maintenance,or future water usage. Inspector's name(print) . �,3► �l��,c� c Y Phone 7�° T License and/or Regi ation Number r,� Address Employed by !� ► Address ,Z - -- Signature 6 - Date Upgrade Requirements Iderlved from Minnesota statutes§115.55) An ITPHS must be upgraded, replaced, or its use discontinued within ten months of receipt of this notice or within a shorter period if required by local ordinance. If the system fails to provide sufficient groundwater protection, then the system must be upgraded, replaced, or:ts use discontinued within the time required by rule or the local ordinance. If an existing system/s not failing as defined in law, and has at least two feet of design soil separation, then the system need not be upgraded, repaired,replaced, or lts use ! discondnued, notwithstanding any local ordinance that is more strict. This does not apply to systems in shorela,7d areas, wellhead protection areas, or those used in connection with food, beverage, and lodging establlshments as defined in law. Suggested Attachments 1) Site sketch could also include: well, well setback to system, dwelling or other buildings,tank(s),reserved soil treatment area, surface water and soil boring locations. Include as-built drawing if available. 2) Soil boring logs, showing each horizon. Indicate the texture,color, redoximorphic features depth to bedrock, standing water and whether the material is fill. 3) A list of any and all requirements of the local ordinance that are different from the state requirements referred to on this form. 4) A homeowner survey of system performance, signed by the homeowner as being factual. 5) Monitoring data as appropriate. Page 2 of 2