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95/19/2011 26:56 7634975011 SPTESTINGINC PAGE 05/09 Parcel number: . .. ....." System status: Is Compliant C3 Noncompliant ' - (as determined by this form) 6draullc Performance and Other Compliance - Compliance Inspection Form for Existing SSTS compliance Issue #1 of 4 Ibate of observation: Reason for observation: This form expires upon next Inspection or In three years,whichever occurs first: (tompllance quest!onslcriteria. (Required) Verification Method*: (optional) (Check the aQpropriate box) (Ghacic the appropriate box) Iboes the system discharge sewage to the ❑Yes I*No Searched for surface outlet 0 ...Jmund surface?_ •__—_,___,..,^.r—I • �� - ❑ Performed hydraulic test lboes the system discharge sewage to drain I ❑Yes ❑ No file or surface waters? X11 Searched for seeping In yard UID hoes the system cause sewage backup ❑ Yes No ❑ Checked for backup In home ihto dwelling or establishment? ��_. ® Excessive ponding In soil system/D-boxes W bo other situations exist that have the ❑Yes No ❑ Hoimeowner testimony 0otential to immediately and adversely , iEnpacl or threaten public health or safety ❑ Examined for surging In tank Celectrlcal,unsafe covers etc.)? _ -I— a "Black soil"above soil dispersal system�40 Any"yes"answer Indicates that the system Is an Imminent reat to public lreaitly and safety. E3 system requires"emergency"pumping G _ ❑ Performed dye lest Does the system pose a threat to ground ❑ Yes ® No ❑ Other: a, water for any conditions deemed non- rotective 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, r_ ..._ in sequential order, nor does it indicate which combinations are necessary to make this determination. Certification ihis form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPGA)Compliance nspection Form for Existing Subsurface Sewage Treatment Systems.Observations,interpretations, and conclusions must be F.ompleted by an inspector. Completed form must be submitted•to the local unit of government within 15 days. broperty owner name(s): _-jAl^M Ihroperty address; _� 0.,, {property owner's address(if different): •.•� �. County _••N - Property owner phone: cI fy 2 -4 7�.�—D atol I hereby certify that I personally made the observations, interpretations, and conclusions reported on this form and that they are Lrorrect. Name iVr¢�1 �'—S Q1�t,ti' L�1 � _ Certification number: (a d7 _ me and number. 5-4 �•�� 1) 1% 40 r)- � 66 or Business license name ��.�.) �� Name of local unit of gover menta -•----- - Signature: Date: �.► - a�=�9 1vww.'pca.state.md.us• 651-296.6300 800-657aWI---,-• TTY 651-282.5332 or 800-657.3864 Available In alternative formats t.,n_un.,fereA.if . oti m/na Page 2 of 8