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05�25/2010 12_18 7634988290 RUSTYS PERC TESTIN6 PAGE 06 <br /> Paroe►number. Systam stetus: �Compllant ❑Noncomptiant <br /> (qg de(�msirrsd by fhis fo►m) <br /> Soil Sepantlon GomPflance snd Other CornPlfance _ <br /> �pl�aace tssue�t3 �4 <br /> Date of obee�vation_ 5l2V10 Reason for obaen8don: Transf� <br /> Thfa�nn ihis fon►►doea not explre. <br /> Complianca qu�stlonsMMtor1�:(Required) Veriflcadon Method"':(OptioneF) <br /> (Clrack the aPP�Pdate boxl �chedc n,e a�ranna�e boxJ <br /> Fo�systems bulH prior to Apol 1, 1986.and not � Conducted aoil obsarvation(s)(attac:h Doring log�} <br /> Iocatad in Shorols�d ar Wellheed Protectlon <br /> Area or not 8erving e food,be►�erege or ❑ Two provivus verifica6ons(eltach borl�g I�gs) <br /> bdging est8bflshmer�t: ❑ Other. <br /> Doe6 the eystem heve et bast a two-fool <br /> vertical separation distance from periodic:ally <br /> setureted sa�or bedrodc7 Yes ❑No <br /> For non-perforrnance sYstems built Aprll 1. <br /> 1985,or Iate.�or for non-pertormanoe systams 5011 OD88(VB�fOf1 d09$f101 EXplf9.PC@Vi0U6 Ob8Bfv8lbR9 <br /> tvcaded in SNoreland or WeHheed Protedion �������t��ara sufficieM,unless site <br /> Areas or serving a iaod,beverage or lodging oon�tions have been alteted. <br /> eateblishmant: <br /> poes the system have a three-Mot vertica► <br /> separadon diatartce from pe�adfcally seturated <br /> soil or bed�ock?" Yes No <br /> For reduced separetion dstanCe systems(i.e., <br /> 'perf�rmsnce'systems undar old 708Q.0178 or ' �Y�►sduced by up to f 5 pe�ent!f a/lowed in lOcal <br /> TYpe IV or V uystem under new 7080.2350 or Wd�neRce. <br /> 7080.240a): "No standard protacd exists This Irsc is not exhausdve, <br /> Does tt�e system meet th8 4e9igned vertical in aeque►t6a/o�der,nol does if Jpdicete whidt <br /> separation distance from periodlcslly setureted Car►binatians ars n9cesserY b make this <br /> soB or bedrodc?' ❑Yea No ���Ae�� <br /> AI�y"no"an�sw�r indJut�►s tMt dw syatem/s f+ping t�pivtoc! <br /> gl+OU►►d W�a� <br /> CertiffcatiOn <br /> This form is to be completed end atted�ed to the Summary Form of the Minnesota Poqution Controi Agency's(MPCA)Compllance <br /> fe►spectlon Form for Exlsfing Subsurface 8ewt�gA Troabne�rt Sysbems.Ob88nretbns,irt�erpretstions,and conclusioi�s inus4 b� <br /> �bY�TM�P�"���-Completed#�EntrsE be sabaAi�teA!o tRe beal�t�t gaveururenl�vlfhin 15 da�fs. <br /> Prvperty owner nan5e{ay: KeiNi Ffitte <br /> Property address: �v�i��ounfrYaide 6rive.Qrono K�[Ft 5�b3�6 <br /> Property owners addresa('rt ailt�q: <br /> C� }{�p;rt Pttorie: '952-N8-97A� <br /> f heieby ceti/y fhet I personaN}'mad6!he observeilorrs;interpretaGons;snd conclusiorrs�ported orr�hrs fomt anc�N►at they a►e <br /> � . <br /> Name: Joseph J Olson Certi�6on number: 1255 <br /> Business ti�anse name and number. Rtt�tY()taon's svit anc#penxiletbr►�9 Uc�810 or <br /> Name of iqcal unk ' of Orvno <br /> Sign�g: Date: 5l25110 <br /> wq-wwtsW-31 Comp(iance lnspectlon Form jor fxist)ng� <br /> 4!4lQD <br />