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e2�e��2ees 13: 39 7634988290 RUSTVS PERC TESTING PAGE 04 <br /> pi;�y py�t�)5edt b Kellpav Bo■ndman Sibe Addr�: 165 Clv�tal Creek R�o�d. <br /> (Pleat�e ai�►rGe the sys�n cza►n�ne�►Cs): <br /> What meH�ods rirere�ad�ma�oe!he delennir�etfon4l�or t1�complfanoe inq�eciion7 (Mde:Ab staiaa►ard p►�tnr�a/e�r�sLs <br /> 7he IbGbwln�g AFst�nr�t'r.�rar�,rtot bi�qu�►�/ader nar h�whAah aarrnbinat�ons aie reea�ry!v mske a afecerminaban) <br /> ld�dlY�o1�� <br /> o Probed bnk Da�ltiwn a Saardxd Tor sl�rfaue a�tleC ■ Ca�dud�)�011 baings <br /> a ob�av�ed bw�iquid le�rel 0 Perfomied►ryd�'�ulk Gest Oeptt����rtdtlng lay�a ,¢�i <br /> � 6carnined oonst.neoords ■ SeaRited for seepin9�yard De�b�sy�em ba�m SZ2 <br /> 0 Ezamk�ed emPh►(PumDed)�nk o O�ed�ed for badc-up In home o 0camined r�our�ds <br /> a Probed a�side tank fbr"blacic soH' 0 6oa�siue pa�ding in 9011 sysbert�/D-baares o t GiJ Limi�nq Lay�er Verfftcatlon <br /> a vre�xe/,raa,um dtedc • Momeo�wr�er h�fmorry o ott� <br /> ❑ Oliw O btamkled ibc slrgl��g In tank <br /> o 'eledc s+�ofi'sboMe snit sy9oe�n <br /> O �tlrer <br /> Based on the cotnplianoe aibaria,the�s�em s�ah�s la (ct�dc or�e) C7 falNn9 ��P�9mundwat�) � an <br /> imrnlnent tt�r�t m{x,blk Nealti,or safieh(T�PNs). C] ran-�omp�f�M(mon�ring �,e). e complfar►t(rwn�f ine 3 <br /> pr�Mous aonditions). Zs tllt�s�m i1 EPA Cl�a V Lbed'bn 1M�!!? O yes � no <br /> T1wrlbrg tltis dopiment!s m: •Ce�Uficabe af Complianoe ❑ Ndiae af Nonoo�n�liance <br /> I��a staoe c#Mbu�a aoer�sed in�or and/or Designer I or Quat�tiad Empla�rae Ir�pec'�or and/or Quallfied Employee <br /> Desig►ier I that I ooriducEed an Investl�atlon d�a�ameaedy�ied the axnplf�rwe stetus of thls s�rst�an and f�at my rEmrtled <br /> o4�ervatlons are aoairaLe as af this da�tte. No debennlnatbn af f�re hydraulk pdiormar�ae has been nor can be made dtee bo <br /> U11kf10wf1 0011�OTI5 QlM11Q Sy5�R7 001'tSGLl�1011,dbUB@�t11C SyS�m,111ddeqlld�ma1�18►10e.Of fu�u1�2 WB�f U52Q@. <br /> In�e�#oi's name(prirrt) .]A�ADII)0�011 PhOnC: Q'�149�,8779 <br /> Lio�ise end/or Reglstration Number_,�,.,� Address: 11481 Rif�nrls�Rn�d NE..HanoMer.MN.5�3�41 <br /> Empk��by; • Address: 11481 Riree�rl�w lioad N�..Henarer.MN.55�41 <br /> ��� DeLe: 02/07/OS <br /> jabA�+d hdn M�ab Smd�s§I15.SS) <br /> M lTPFlS m�l'de�reder��or�us�c+�ar�i�d w�Jabi�ma►�fes aiie�it aFd�s i��e or wmb►�s(I�a SJ�p►l�pier9iod� <br /> iaqul�c+d by br.a/ar� lJ�dhie sys�m 1do�'s l��oml�i'!e sulfll��p�d�a►�d�e sy�em m�nt de u�rap� <br /> r�fa�d,ar/�tts�dLs�r,�ed w�ii rhe l�ne�qr�ear vy�ute or H,�e brar ad�an� 1fFan e�rg sys�►n�n�a�g as a�n�d dn <br /> AA�ww,and/A�ts a��asf 1Nb 1l�et r�f ate�n s�f.�qpnisbfcer�dh�n�h�e systern rae�ed n�at B�e r4D�eded,�alred,�o�d,ur/L+s t►s� <br /> d�b�ru�ed,non�/�Ing anY Ao�/ore�n�tlret[s movp sb'�tcL 77Ks abaes n�nt app�y lo syst'ernsln.�fa�nd a� rr�d <br /> Prol�6ian�cr U�aewe e�ad br uarm�adrbr�rn�li f6iad,b�rag�and Aaai�dr�g��a�efu�ed!n Law. <br /> 1) SfDe 51oeGch vr�tidl U�des ttle sy�oem loratlo�(marlbaoory). qt�er i0errs oould indude:w�eN,vrell sfltbadc tn s�►SCem,dweNing or <br /> otl�bulldings,�nlQs).res�v�d saN trratrna�t ar�,surfaoe water arid 5oB boiing lowtlon.s. Indude agbuiR drawing if avaf{�bie. <br /> 2) Sdt borin9 logs,showMg each horfaon. Indical�E the texture,aolor, rado�norphic f�eafiures deptl�bo bedrock,standing water and <br /> rvhe�the mate�lal ts 1�1. <br /> 3) A list of arry and ad req�n�ts o�the bd ordlnanoe titia�t are dlfl�erer�t ftom the stabe requlrerr�+tts referred to an thls form. <br /> 4) A txxr�eawr�surve�r af 9ysGern DeHbnr�anoe.sir�neA bf►the hOmeoyvrler as b�[1g f�dLal. <br /> ,57 Monlborir�y dats as apprnprta�6e.3025 <br /> Page z of a <br />