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07/19/2011 21:33 7634975011 SPTESTINGINC PAGE 63109 <br /> Parcel number: �, , System status: �Compliant ❑ Noncompliant <br /> � (as det`ertnfned by tl�is farm) <br /> Hydraulic Performance and O#her Compl�ance� Compliance Inspection Form for,�xisling SSTS <br /> Compltiance 15su� #1 0#4 <br /> Date of observation: �- � 1 � ��._,_,� Reason fnr observation: �����-( ���w.i� .4�'�'� <br /> 7his form oxpires upon next Inspectibn or in three years,whlchever occurs first: _ <br /> Compliance questions/criteria: (Required) Verification Method': (Optional) <br /> (Check Ihe eppr�priate box) _.,_,.,� (Check the app►apriate box) <br /> Does the system discharge sewag�to the (]Yes � Nv � Searched for su�Face outlet 1J0 <br /> c�round surFace? _ ,. <br /> ❑ PerFormed hydraullc test <br /> Does the system discha�ge sewage to drain ❑Yes ❑ No <br /> tlle or surface waters? �I Searched fo�seeping In yard �N O <br /> Does the system cause sewage ba�kup []Yes � No � Checked fOr backup in home <br /> into dwelling or establishment? _ _ � Excessive ponding in soil system/0-boxes hl0 <br /> Do other situations exist that have the ❑Yes �Na 0 }iomeowner testimony <br /> po#ential to immediately and adverseVy <br /> impact or threaten publlc health or safety ❑ Examined for surging in tank <br /> (elect�ical, unsafe covers etc. ? [�] uBlack soil"above soll dispersal system �.6� <br /> Any"yes"answpr►ndlcat�a that the syst�m Is an imminen� <br /> th►eat to publlc hgalth and safety. ❑ 5ystem requlres"emergency"pumping <br /> �------ �] Performed dye test <br /> Doas the system pose a threat to ground ❑Yes � No ❑ Other, 1��!��I,l� �(¢�'4.5�C-1•�4 <br /> water for eny conditions d�emed non� <br /> �protec�ive as determinpd by the ins eeto� �,�.1�.y�b�'�. <br /> "Ye�"indicates thet tl�e sysiem i�failing to protact <br /> ground watei If"yoes'; descn6e tho condition nntod: <br /> "No standard profocol exisfs. This lis�is nof oxhaustive, <br /> ___..,_._ in sequenfia!order, nor does if indicate which <br /> combinations are necessary b make this determinafion. <br /> Certificafiion <br /> This form is to be completed and attached to the Summary Form efi the Minnesota Pollution Control Agency's(MPCA)Compliance <br /> Inspectian Form for Exlsting Subsurtace Sewage Treatment$ystems.Observatfons, interpr'etatians,and conclusions must be <br /> cvmpleted by an lnspector. Completed form must be submltted to the local unit o�P government within 15 days, <br /> Property owne�name(s): �l,�'„���,f��l-�t�9�� ,_. .,_ <br /> Property address: a�_t� �+�t �'�,�� �����L�.�d��� <br /> Property owner's address pF dlr�arent): � ,.,_ _ .� <br /> County: '� � �%''�,4„S� --- Property owner phona: lo lZ-- 'J'ZO --� t.4 7�.�� - <br /> 1 hereby certify that 1 personally made tife obseNatfons,interpreiafions, and conclusions reported on Niis form and tha�ftiey are <br /> conect <br /> Name: 5��;,!,;(3_, S L1��_5��'QS Certiflcatlon number: loa n <br /> Business license name and number: S ��''`��1�1� 1�.1 L � , 1..�C. �'?t�!-�__ 1°�2�=�J° �'3_��A+� or <br /> Name of local unit o'f govemment: ,. , <br /> Signature: '��-�`� �,,.�'?9 _,,-._"-�, _,.,.. D�te: -� ��Q�.� <br /> , ., .. .--.- .-- .�. �ni .�nn onrl G[7 OOt.I . TTY 6F�_OC'!_C79��.r flAfL�C7.�0.LA . Aveilahla in olhnmePi�ia fn��ne4e <br />