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, �ril�per�y Ovirner(s) `17C��.\La� "�''1�Y��..1 r' ']d�-'�,
<br /> —__IFir�e �I�e/ Paa-cel �1�.
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<br /> systein components (P/ease descri'be the system componentsandattach slfe sketch showingsystem/ocation):
<br /> �'�{;�"g'�'tn�1 �� �� � � " � ��"�- �!, � t, � '
<br /> '� f--�-� 'b—' '�4-^�4�4f�.�r S4(/�"C��.�=..�'1�1 u),ti�*',t-k . 1[���Sa> 1�l ,
<br /> �1v�G =�,,� �t t'�''�. �"� � "'�"'�'���.1c`�..��:�-� , r .
<br /> . � : ' t�a�_51�\`� � : t7 _1�,
<br /> �1/hat'method�wA�A.,�a,�F ,ake th d �l�erminatfon for ' —
<br /> combltan�� ln�.,��g ?(Note;/1/ostandardp�otoco/ex/sts
<br /> The fo//owing/�st/s not exhaust/v� orin s�uenUa/ordernor ind�cates rvhlch combinat/ons may R�eS�ry to�lake a dete�mination)
<br /> �Ila�ertlgf��tank(s) Hydraulic Funct(onBn�
<br /> ❑ Probed tank bottom. ������S�paratiott p��taea�e
<br /> ❑ Searched for surface outlet
<br /> ❑ Observed low liquid level � � Conducted soif borings
<br /> ❑ Performed hydraul(c test !
<br /> ❑ Examined const. records ' peP�i to I(miting layer. 3� ��tr�����
<br /> �M Searched for seeping in yard }.1(�
<br /> ❑ Examfned empty(pumped)tank ❑ Checked for baelc up.in hoii�e Depth to system bottom d��d���0�p��
<br /> r� Probed outside tanlc for"black soll" � Excesslve pondln�In soll systemJD-bo�xes � �amined records
<br /> ❑ Pressuce/vacuum check . LGU Llmiting Layer Veri.fication
<br /> ❑ Nomeowner testimony . �
<br /> ❑ Other � Other
<br /> ❑ Examined for surging In tank
<br /> � �r "Black soil",above soll system�Q
<br /> �. Other
<br /> Status of th� syst�m
<br /> �
<br /> �ased�e�tl�e complsance c�iter�a,tF�e systern��atu�s_i�o (check one) � falling (to protect�gr�undwater ❑ an
<br /> imminent threat to public f�ealth or safety(ITpHS)��p nori compliant(monitoring tssue) C7 cbnip►iant(none of the 3
<br /> previous condit�ons). Therefore,.this.docuenent is a; ❑.Certificate of Compliance L�.Notice of iVoncampliance
<br /> �s this systeQn an EPA Class V Tn'�c�lon.�il/ell? ❑ es C�# ho
<br /> CertifCatior�. a
<br /> I.hereby certlfy as a state of Mlnnesota licensed Inspector and/or Desfgner I or Qualified Employee Inspector and/or Qualified Em
<br /> Designer I tf�at I conducted an investlgatlon tl�aE accurately determined tf�e complldnr.e status of this syStem and that my recordedfoyee
<br /> observations are accurate as of thls date. .�No determinatlon.of future f�ydraulic performance has been nor can be made due to
<br /> unknown condftlons during system constructlon,abuse oP the system, lnadequate maintenance,or future water usage.
<br /> Inspector's name(pr(nt) �-� ��� � �'�. ���`��,�_� � �
<br /> License and/or Registratlon Numbei-��� �� P�������� � ��� � ����
<br /> � Address�,� �y������ �� , ���
<br /> Employed by�-'��`b?�� 13.4(��,
<br /> Signature__�"-�-. ��
<br /> !r Address �� �`�1 t L 1,��-�,�� �'1 1� .'�.`.,��/
<br /> � ���.�"
<br /> -----�-m.�..�-..,...
<br /> �clr�de ReqUir�ments _(der/vedfrom M/nnesota Statutes, Date_ f �" � �-}•��
<br /> An ITFHS must be upgraded,r�p/ac�o�Its use d/scont/nuc�d iy h/ir ten months of rc�ce/pt of tfi/s notice or within a shoi-te�. riod 'f
<br /> �equire,�by/oca/ordinance. If th�system fa1/s In pro vide su�c%ntground�vater prote,ct/on then the
<br /> rep/aced, or/Ls use discon�'nuc�d svlthYn the time requ/red by ru/e or.the local orrJ/nance. Ifan ex/st/n � /
<br /> /aw,.and has at/east�wo feet of d�s/gn sol/sepa�ation,then the s � s3'stem r,nust be upg�aded,
<br /> g system Is not fa///ng as defined in
<br /> discontlnuecl,notw/thstand/ngany/oca/o�/nancePfiat/smorestr�e7/1/����p�y o��e�s�p��/a darea� we//head
<br /> protection areas, o�h5ose useYJ/n cnnnecCion yvith�'ond,beveiage,and/odg/ng estab//shntents as defined In/aw.
<br /> suquested AttachmPn��
<br /> 1) 'Site sl<etcf� cou(d also.Incfude:wefl,in�ell setback to system,dwelUng or other bulldin s tank(s),reserved soil treatment area,
<br /> surface�waEer and soff'boring Iocatlons. Include as-built drawing (f availa6le. 9 �
<br /> Z) Soil boring logs,sNowing each horizon.`Ind(cate tf�e texture,color,redoxfmorptilc features depth to bedrock,standing water and
<br /> whether.tt�e mater(al is flli.
<br /> 3) A�lst of any.and alf requfrements of the.local ord(nance that are different from the state requirements referred to on this form.
<br /> 4) A homeowner survey of system performance,signed by the homeowner as being factual.
<br /> S) Monitoring data as approprfate.
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