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Property Owner(s) Fire No./ Parce) No. ...................................................................................................................................................................................................................... Svstem Components (Please describe the system co ponents an attach s� ketch showing system location).• c �t✓ �" �0 tl k.,c/ c� /✓ ��-� / What methods were used ta make the determinations for the compliance inspection? (Note.�No standard p�otocol exists. The fol%wing list is not exhaustive, or in sequential orde�nor indicates which combinations may nece5sary to make a determinatron) Watertight tank(s) Hydraulic Functioning Vertical Separatioq Distance ❑ Probed tank bottom �(' Searched for surface outlet � Conducted soil borings J� ❑ Observed low liquid level ❑ Performed hydraulic test Depth to limiting layer �l ❑ Examined const. records � Searched for seeping in yard Dept ��t� botto�n��'K �J /h�d� '�'� 'J / rpt Ex�r,nined�mpty�pumped)tank ❑ Checked for back-up in home ❑ Examined ecords �j'�P��,�y�� �D c.«.•o ?,� ❑ Prob�d o tside nk for"black soil" ❑ Excessive ponding in soil system/D-boxes ❑ LGU L(miting Layer Verification ❑ Pressure/vacuum check ❑ Homeowner testimony ❑ Other ❑ Other ❑ Examined for surging in tank ❑ "Black soil"above soil system ❑ Other Status of the svstem Based on the compliance criteria, the system status is: (check one) ❑ failing (to protect groundwater) ❑ an imminent threat to public health or safety(ITPHS), � non-compliant (monitoring issue)�compliant (none of the 3 previous conditions). Therefore, this document is a: � Certificate of Compliance ❑ Notice of Noncompliance Is this system an EPA Class V Injection Well? ❑ yes �' no Certification I hereby certify as a state of Minnesota licensed Inspector and/or Designer I or Qualified Employee Inspector and/or Qualified Employee Designer I that I conducted an investigation that accurately determined the compliance status of this system and that my recorded observations are accurate as of this date. No determination of future hydraulic performance has been nor can be made due to unknown conditions during system construction, abuse of the system, inadequate maintenance, or future water usage. Inspector's name(print)�D��k/ .fV� 'l-��'�✓ Phone ��i .�'"'Y7g'- ��iZ� License and/or Registration Number .Z l Address �� Employed by Gl� r✓� �� S�' Address�O� � -� S/ Signatur •-�- Date �' r� Uaqrade Requirements jderived from Minnesota Statutes§115.55) An ITPHS must be upg�aded, �ep/aced, o�its use discontinued within ten months of receipt of this notice or within a shorter period if requi�ed by local ordinance. If the system fails to p�ovide su�cient groundwater protection, then the system must be upg�aded, �ep/aced, or its use discontinued within the time required by�u/e o�the/oca/ordinance. If an existing system is not fai/ing as deFned in law, and has at least two feet of design soil sepa�ation, then the system need not be upgraded, �epaired, replaced, o�its use discontinued, notwithstanding any local o�dinance that is mo�e strict. This does not apply to systems in sho�eland a�eas, wellhead protection areas, o�those used in connection with food, beve�age, and lodging establishments as defined in law. Suggested Attachments 1) Site sketch could also include: well, well setback to system, dwelling or other buildings,tank(s),reserved soil treatment area, surface water and soil boring locations. Include as-built drawing if available. 2) Soil boring logs, showing each horizon. Indicate the texture, color, redoximorphic features depth to bedrock,standing water and whether the material is fill. 3) A list of any and all requirements of the local ordinance that are different from the state requirements referred to on this form. 4) A homeowner survey of system performance,signed by the homeowner as being factual. 5) Monitoring data as appropriate. Page 2 of 2