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+ Property Owner(s) r7 A-fZ /20 /�2 Fire No./ Parcel No. ......... . _....... .............................. . ......................... System Components (Please describe the system components and attach site sketch showing s s arl locatiO ): J' D,,2 What methods were used to make the determinations for the compliance inspection? (Note:No standard protocol exists. The following list is not exhaustIve or in sequential order nor indicates which combinations may necessary to maks a determination) Watertight tank(s) Hydraulic Functioning Vertical Separation Distance ❑ Probed tank bottom lei Searched for surface outlet Conducted soil borings O Observed low liquid level X Examined const. records 0 Searched for seeping in yard Depth to syster-i bottom V1d� } r ❑ 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/vacuurn check Homeowner testimony ❑ Other _ o Other Examined for surging in tank CJ "Black soil"above soil system Other._. �' I rrrr CwP/L Status of the system w. Based on the compliance criteria, the system status is: (check one) ❑ failing (to protect grotirclwater) ❑ an imminent threat to public health or safety (1TPHS), ❑ non-compliant (monitoring issue)Acompliant (none of the 3 Previous conditions). Therefore, this document is a: Xcertificate of Compliance ❑ Notice of No icompliance Is this system an EPA Class V Injection Well? ❑ yes X 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 wage. Inspector's name (print) L5 llP Phone 3 479— J License and/or Registration Number (, Address l��O 6".✓YL/ )2 F-3 Employed by T Address &421eUT &n/_ Signature c tq._ Date Upgrade Requirements jderived from Minnesota Statutes g 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 equired by local ordinance. If the system fails to provide sufficient groundwater protection, then the system must be upgraded, replaced, or,t57 use d1scont1nuEd within the time required by rule or the local ordinance. If an existing system is not failing as defined in law, and,5as at least two feet of design soil separation, then the system need not be upgraded, repaired, replace], or its use dyscOfMrued, notwithstanding any local ordinance that is more strict. This does not apply to systems in shorelana areas, wellhead protection areas, or those used in connection with food, beverage, and lodging establishments 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 t-eatment 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