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104/15/2010 11:58 7634988290 ;RUSTYS .PERC TESTING PAGE 10 <br /> Penal number: 0411723220032 System status: ®Compliant ❑Noncompliant <br /> (as determined by lids form) <br /> ""mulimla performance and Other tComplinnoe <br /> Compliance Issue #1 of 4 <br /> Dote of observation: 4/12/10 Reason for observation: Property Transfer <br /> This form expires upon next inspection or in three years,whichever aocurs first: 4112/13 <br /> Compliance queetlonsloriteMa: (Required) VerHicatlon Method":(Optional) <br /> Chock the rials box (Choi*the appropriate box) <br /> Does the system discharge sewage to the ❑Yes ®No ® Searched for surface outlet <br /> round surface? ❑ Performed hydraulic test <br /> Does the system discharge sewage m drain D Yes ®No ® Searched for seeping In yard <br /> We or surface waters? <br /> Does the system cause sewage backup ❑Yes ®No ® Checked for backup in home <br /> into dwellf or establishment? i [1, Excessive ponding in soil system/D-boxes <br /> Do other situations exist that have the ❑Yea ®No ❑ Homeowner testimony <br /> potential to immediately and adversely [ Examined for surging in tank <br /> impact or threaten public health or safety <br /> etecbieel unsafe covers etc.)? ❑ %lack soil"above soil dispersal system <br /> Any"yes"www indkaess that Me:ystwn/s on limn"d ❑ System requires'emergenaf pumping <br /> threat to public hwft and salisq►. <br /> ❑ Performed dye test <br /> Does the system pose a threat to ground ❑Yes ® No D Other: <br /> water for any conditions deemed non- <br /> as determined W the i <br /> "Yes"indicates that the system is failing to protsmt <br /> ground voter.N"yes",dascdbe the condition n0110d. •No standard protocol exists. This Nat is not exhousHve, <br /> in sequendal order,nor does it indicate which <br /> wndi owns are necessary to make to detetminoWn. <br /> Certification s <br /> This form Is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compliance <br /> Inspection Form For Existing Subsurface Sewage TrOdment 8jystems..0bservet1or6,interpretations,and conclusions must be <br /> completed by an inspector.Completed form must be submitted to the local unit of government:within 15 days. <br /> Property owner name(s): Baker Homes Inc. <br /> Property address: 3085 Watertown Road. Orono. MN 55359 <br /> Property owner's address(If di <br />