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e6/30/2e68 21:47 7634975611 SPTESTINGINC PAGE 03107
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<br /> • I ?,/25/07_ � Water/Waslewater-l.STSq.31
<br /> ��? ��,pa��,`������rn��,�rn�����f:ao� I�o�'A7� '�rar I��u:�'���ac�
<br /> -._..�.. Ta���d�r����� ��v�rag� �"A��a���r��►nL �gr���*mi�� �in�,e��� �o�iut�orn
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<br /> • C�ok��:roL.Agem��cy
<br /> Camplet/an of thls f�r,m fu!!lll�rha rrilnlrnAl,:Pyuirorr�snfs o�ay/nn,Srar§ �16.65(,200'1)•andMlnnosar�R, ch. 70140,�j999�. Plpase rr•:tr�r
<br /> �o loc�l ordfnap�os roK�tlivr roqu�r.eme�ta pr ln(ormatlon e�eclail f r:com Itance re utr¢menis,For bedroorn acl�iitlons
<br /> Ger��ral:� � � , ... . • '� - '-_�
<br /> �ata�f�n��pec2iot�; )�l-y —o� I�m�,so�fo��nsp�cl•lan� .�'��_�y�1Q-5.!<��.
<br /> �ropei•l.y�U�nr�erC�)`�'�G_�1-� ��IA�L�.�'�..�i� • �'epe k�on� ..
<br /> � � (�I��u��23
<br /> �ers�on requ�stpn���rt��Jieetlam� _41�}Y►✓ti'�, 'TeBepl�uon�C )
<br /> Slte,1�1dd�-e�s �.'� I�0 G�o � � ' � ' .
<br /> � " � '=�--��LJ���'1!�p��� zi� C�od�e-�.�.`
<br /> Fii-� p�o./ P�arc�9 nlo. - . �atGta$�/.,-��.1,15'6Q 1 1J
<br /> ,`�'—„ I "— __.fbiNt�sO�ip�. . .
<br /> L�gal D��criptiron . ' � .
<br /> �oc�l Regiafatot��utl�or�lZv L�^��p� �
<br /> 1Da�c�y�o:��n co�tsiruck�t9_�c� O Q � . _ � -�_
<br /> :�ysk�m R►n �l�or�el�nd/A�ea, yes �i Sy�teret ir�Vle�ll,O�ca�
<br /> Fro��cl'Bvn Aro�,: yPs r� Sy���eta��erv9rt����7�)!•� 41c�aisa�l fa�cpAily: yes Fio �.o��l�&'�rm�k� (I�anY)^,
<br /> �� ---.�..�
<br /> S�+sl-ems L�uill:pr�or to April 1',, 7.996 tincl 1�ofi I,oci
<br /> �ted In �y.sl•enns�loc�ted en�Sl�oreland�pr Wcllhead,prol'ectinn
<br /> Shoreland �or Wellhe�d Protectfon'�rea o�Selving a-FoocJ,
<br /> . , , qre�s mrt•SetVing,a.Food;Beverage.or'Lodging
<br /> B�verage o�I.Odgil7g F„stal�lishinc��l:� � C�l'ab ish�ren ��
<br /> . . � 4 sYstems F�utlt�4���r
<br /> � � ' � = March 3:l 1996 '
<br /> Is tl�e��sLem ah !m . ..nent 1; r�a t�o ��lic h����th Dr ��s�L• .s 's•e� n � ine thre �o . 0.GbI�C oie�lt
<br /> sa eLv? (s y�s anst�rei f,�an�77'H�'s'}�st`cmJ•'. 'o����fe ��L�p,—,--,
<br /> -�ischarc�e of seW�ge to ilie, rouncl surfatel5 . 4Y�'��'}�s��n.tfNerls,�n,I7�f�5�'systernJ � �
<br /> � , YC� NO -D�sci�arge oPsewage to LI��c�round,;urface? YFS NO
<br /> -Ulscharge c�f sewage to dnirillfe or surfaCe w�ters7 YG; NO � �
<br /> -Scwage t�acla,�Into r.IweQfng? � - afscha�'ge of,*ew�ge to,drafnllle or surface watCrs?Y�s
<br /> �• � -Yr:S NO �SeW�ge,.h��lcu�InFo dvVelllr7g7
<br /> -Sltualion wllh the pot:enllal to fmmecllal-�ly ancJ ' � -Sll7,l�llon wltll the pqtenL�al to lmmedlately�n� �v�$ N
<br /> acJvcisely(mpa�t or khreal�en publ�c I�e'a1tF�or ' - �ac�versely Imp�cL or i;flreat�e� public h��l�l� or
<br /> s�feLy? . ' YE_S NO� safety7 , . .
<br /> Zs Qh�s 5tei � - . , , Y�s No
<br /> 1'--�!fa�,illq� (a-J�s,ans��e�l.�.a fa!l/Rqsys(�mJ T�•Ihe a rar� -faili �. '
<br /> ��.ess i;h�h T`Wi�fePl of veri]cal,seh�r�� h I�elw�en� � � .��-�a J�'s.�nsrHer is a fa!linv system)
<br /> -Les�Lhan���IF�E�feet oF�ver.tic�l�separatfo».bctWeen
<br /> SySltlm•��OttoRT�ahd satturaLed sofl or�b�drbcic7 ' � �� �Y�S -�NO -•syst,-�ri�bot�om aricl�aki.i�atecl so11 or bedrocic?
<br /> -A ser•_page pii:,cesspool,drywell, orCeac�iing pll7 � YFS 'NO Y�S
<br /> -A�see'p�ge plk,cesspool� drywell, or leacl�ing�(t7 Y�5 Nv
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<br /> �.��s3Cst ►�j�go. �co�r �li_ �►il� � � � , x��'1e .
<br /> ��Is th�syst�m regiilatad•unr�er a mo 1to'rfn. I�n'or � '—��$ � �.➢O ^ 4 ���n�� • .
<br /> o �� -� I� ihe' sy�Y�rr�-r�gulatecl unde� a ,monitorin,g p�an o
<br /> peratin� pBrmit? jif no,.Ao fo pagv . Y�� NO ' v�eratinp�o�mlt?'�if no,yo�o pago•2) ' YES 1O
<br /> Il`yes, ,'
<br /> -I•las tho roqu�rod montloring fal<en p+�r-,e? ' y��, �� Ifyes,. � , ,
<br /> (�fno, th9 s��srem!:�non�complying) ; : � -Flas ihe reqUfrecl mo�iltoring'l��lcen plai;e? � YE5 NO
<br /> , , �, , (If no,7he s�rsfam/s non-c�ci'rnplying) .
<br /> - Dnes.thh monitaring fndicata.th�t tlitl sy . .. �� � . . �
<br /> �rFo'� �h� i , aFerri rnobts �poas�ih�e mbnitorin tndi�ate�th�it't�n s s
<br /> p n� c� expecta,tio'i��'� �� � � . ,� , . ,•� �- '�O • : .. � .,.•. . , 9 , I y tom tne�qts
<br /> .(If.�no, :Ctio;sysfomf.s•rio . . .. - .9� � ; � , �YC.'�- . , �'., pelfti'tmar��q:e��pectatji�ns? , . , .
<br /> � .�. , n-camplyln , (Ifno, thesy�tsm,isnrrn�-co ���n " "� ' YCS� NO
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