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. 07i26/2665 09: 55 7634988290 RUST S PERC TESTING PAGE 04 <br /> p�,0perky pwdter(s) Mark�jnson �ts Add . 44bS da R�d <br /> (P�t�e desr�de tl�e sysl�m c�mp�arae�ats): <br /> . <br /> What metl�ods were used eo n�ake tf�e debortninatior�s for tfie oam ianoe lnspection?(Note:Nh sYanararriproto�cn/ex,'si� <br /> JJie fidbrving l,(st is nAt�haus�nat in s�pr�enb�/ovt�fer�r ir�tes wh axnl�i�oons are n�ry ta make a de�r»�Mad"an) <br /> I�f� � <br /> O Probed�Nc bot�m • Searchad for svrfaoe outict v Canducted soll borings <br /> f:J ObServed low liquid level O P�etformed hydreulic test Depth bo limf�ng layer �4 <br /> a �camined oanst.reaords � SearChed for seeping In Deptl�Lo sysbem bottiom�$ <br /> i Examined empty(pumped)tank ❑ d�dced fbr badc up in ❑ 6camined reaords <br /> o Probed ouCside tank for'blacic sdl" • 6coesslve ponding in soil /�ba�s O WU Umi�ng LaYer Verification <br /> o Pres�,re/vacuum ch�dc o Home�wner�e.stimony ❑ Other <br /> o Other o Examined for sUrging In�n <br /> � "Black soil'above 5oU <br /> a other <br /> Based on tfie oompllanae criteria,the sy�n�s Is: ( one) �I falling(bo protiect gr�oundwaber) ❑ an <br /> imminent threat to publtc health or safety(ITPHS), ❑ non-oompliaM(mont6�nng issue). ❑ oompNant(non-of the 3 <br /> pnevia,s mnditbns). is thls s�sbsm a EPA CJass V i�eciion 1? ❑ yes i no <br /> thls document ia a: � Certific�rDe af Com Ilanoe ! N ' of Nonoom ianoe <br /> Certlfkat�o� <br /> 1 heneby certify as a stabe pF Miru�esota lic�sed InspecOa'and/or Desgnef I QuallRed Employee Inspec�a+'andlor Qualfied Employce <br /> D�sigr�r I ttiait I oonducted an inve�igatlon tltat dtcurdt�efy deberntined ttle pllan�e s�4js of this 5y50em and that my reCOMed <br /> observatlons are accuratie as of thts da6e. No detemilnatlon af future hydra Ik performanoe has been nor pn be made due to <br /> unknawn ooridltlons duNng sys0em construcdon,abuse of the sysbeari,lna ua�+e mair�enence,or future watier usage. <br /> Inspecbors name(print) w,one: (ye3��ws-�87r.i <br /> Lioense and/or Registration Number 810 Add�: <br /> EmplWed bY: ' Address: <br /> Slgnab�r+e �aLe: Z��a�os <br /> (dey�d fiam M/n�om S�1rd�s§115.55J <br /> An must be upgra�o�r,��aor i7s«s�dlst�ndnt�d wr[filn lan o�"reia°!�of dris noi�ae ur w�'h/n a sharier p�er�'oC If <br /> n3quin�d by Aa�l a�lnan�re ll`the sysl�m fa!(s In provin�e�ig pvot�c�r�, �en�e.syst�.wn must be upgrad�d, <br /> r�d� ar i�s r,cs�di�anlinu�ed within d�e Ome raqudred by ru�e vr bhe avt�0lnance If an exis�ing sysh�m is n�failinq as a�el9i�ed in <br /> Aaw,and i�s at le�st tw�faet of G�n suN s'�oaia�ian,t1�en d�e system nat de uP9rarAe�d�poai�d,�oae+d,aw kr us�e <br /> d�anb'nued, na�wiUis�n�ding any Aaa/orrNnan�Ghat!s moore s�t fi�fs nnt a�ly ta sysl�ms/n s�lend ar�as� r►�e,Vhe�d <br /> Pva�aO�Ov►a2�,or d�e u,�ed in aann�c�an w�i haoid,d erer�,and �tabVls�hmen�s as atel�ned ln/aw. <br /> i) Sibe s�ce�cft whlch tndudes tfie system loc�tion (mandat�ury). Other" oould indude: well,well sel'back to system,dwelling or <br /> atfi�r buildings,tank(s),reserv�ed soll tr�eatrner�t area,surface waEer a soil boring loca�a�s. Include as-built drawing if avallable. <br /> 2) Soil bo�Ing logs,shawing each horiwn. Indic�abe the bexture,o�lor, morphlc features depttt bo bedrodc,s�nding waber and <br /> whether tite materlal Is flU. <br /> 3) A flst af any and all requireqrients of tl�e lod ordfnanae that are d from tt�e staGe rt�ulrements referred�o on this form. <br /> 4) A hort�eowner svnreY of sy�em Pe�ormance.519ned by the as bdng factual. <br /> S) MoniLoring dafa�.s apprnqia6e. <br /> Page 2 of 2 <br />