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bli13/1b1� 02:07 7634975011 SPTESTINGINC PAGE 03/09 <br /> - M",."�5p�, P�"u���" � Compliance Ins ecfi�o <br /> � ControJ Agency p n For <br /> 520i�faycKeRaadNorti� �xis#ing Subsur.face Sewa g e T r e a t men t � $fems m <br /> St.Paul.MN SS1S5-Rt9a Y . . ($S'y-S� <br /> n��T✓Po=Compl/aYice end En/or�empRt <br /> � lnskructions on page 7 <br /> Summary Farrn (comp�eted fo�m � <br /> must be submitted ta the Ipcal unit of government within 15 day�.) <br /> Per�c�1 numbor. <br /> -_ —_-��.—�--�_ <br /> SYs►Pm status: �Complianl ❑Noncomplian( -- <br /> ------ <br /> For local Tr�Cking Purpose�—` — <br /> (bAse�I or�alt cpmp172nCe�quiremenfs) ~�i <br /> . I <br /> Property information —� � � <br /> Properly�wner name(s); t�`~-'—�I <br /> .�1�1"1\�.,��1� ` A►ap� <br /> ProPerty BddrRCs: �J--=�."'� -�!���G.— Property owner phono: 9SZ-�►?aI'- q'ZO,� <br /> ProPerly owner address pr dlfleren��: ����r���t--�.��`1 C7 — . <br /> County;�{�j��Q�,� . ---�-- • ---,— <br /> ���A syslem Constructpd: Permllting Bulhbri�y; ;4�� • �_„� <br /> �.�QO� �'�4��__ . <br /> �___ Reaspn for Inspection;�Q -��.-�_ <br /> 5yste� Description ����5��� .�_� <br /> I� 1 2S'oOya�S'a.�:c-Cca,�J� <br /> B�Pf SySIBm�egcri HOn; ,..• • � ' <br /> n � �000�a„j��l.�� �_tvd� <br /> . t_ocai permil numbec -r�—°��- �?�+?G <br /> �' Nurnher of beclroa�9: ���*M-��'�-'��-� �G <br /> IS khe syst�m: •�� —5_ Design flow raEe: �����" <br /> � `� 1 u��eyT t���a �A4-A��� <br /> 1�Shoretand:��ay . � - <br /> d Yes � Np In WeIlheAd Proleclion A�ea7 <br /> An U,g, Envlronmen�y�Protection ❑Yes �No <br /> �gency(EPq)Ciass V�njoctlon wep� 5ystam serving a Mlnnesota pepartrnent <br /> - ❑Yos •� No 'of Healh(MDH)Ifcensed f�clliry7 ' <br /> C�rnplianCe St�tuS (eased on s�a - . Q YOS f�No <br /> Based on the inFarmafinn gathere�i and rePa'rted on altacl ed Formsr lhe compllancerst tus�f thls s'y) . <br /> � Certfflcate of Cornpliance-valid until(3 yeArs from dale of report): ystem is(check one): . <br /> ❑ Nolice of Noncompltance-For Nr�ncompliant systems: ^ <br /> The reason for noncompliance fs; ' <br /> This noncompliant system Is classlfied�(checic ono below�� <br /> d Imminent threat to puhllC haalth$Sefety �]Fa;ling to proteCl groi�rld wale� ❑No�;n compliance w(tll oporsBn <br /> Certific�tion 9 Permll <br /> !he�eby r•ertify(hat a/I fh�nacessary'/nforma�ion has been g�fhored to detarmrne!he compliance s►a(�rs of ll�fs sysfem,No <br /> delo�minallon oI hnure system pertormance l�as bAen nor esn f�e mado due to un/cn�wn conAitions durin <br /> possihle ahtrse of fhe Sys�am,inanequate mainfenance, or fu�ure water usage, s stem <br /> NamQ� <br /> 9 ,Y ct�rlslruclion, <br /> —`'�-�.��. Sc.N-���s— <br /> Busingss llCengg narne an(1 number ��� .,� --T-- CartlfiCatlqn number. (Q ��� <br /> Name oF lo��unit of g�ve enL ��-��' '��C L� �' ~—���"'� <br /> /=—V. �- � �-t7�-�_�'s3�bl�,or <br /> 5ign�ture; �' ----_�._ <br /> �-�—�-- Date: `��(y201 O • .- <br /> Required Attachmehts . —�--�_ <br /> � Hydraulic Performance <br /> � Soll Borinc�Lvgs �Tank Integrity , • <br /> � Soll Separallon � OPe►'ating permlt Form (if appticable) <br /> �Syslern drawing/As-huilt draw{ng [] Any local requirements lhat aro difFerent from what is required on <br /> ❑ Other Infnrmaf.�on(ilst): • th[S form <br /> Upgrade RoquirQments (de�lved from Mfnn. Staf. 'l15,55)�— � <br /> �Pplece.d,or fts use d�sc�,��u,�ed wnhin� § �n Imm(nent fhrgst fq p�p)��17ePlth anrl� �� <br /> ialfinglo profod gmtmd wgfe�the r.ysfem musl�Ge u`rb�!of thrs nof/�1g or Wrthln e eho�Ter porlo�//fre u�d be�b�TPNS m�.�st pB �` <br /> ex�sU�p$ystem Is nql fau 9 y ce/o�AiRante,/J�h���ed, <br /> /� d'BPl�ed,or qs vy@ Ul�nlfnu9d wlfhin lha.[Ime requ/rEd b �� SYslem k � <br /> �A�d2//nad in lew,end 1�es et leec�rwa foe�o/des/ n splf se <br /> rr�plecep.or fts use d►scpnflnugd,nOfwHhS[9rtding ony local ord{nence thal is tn8 �aflon,fhen ti�SySfem neep n��i pqrade�d,•rQ�,1•o�, <br /> eraaS,Wppry��p��ectlon,MeaS.or those used in con aa slr(eL Thls ro <br /> necflo,i wlfh/opd,bgveraga,end!a p "lslon does not epplY�o sysfoms!n shorefand <br /> ``�~--- �8'�9 astaDAshme,Ms es deCnTed In law. <br /> `xv�c.pca.state.mn.us � b51-�96•6300 . ' <br /> Wq•�wvtsts•1-31 • ai tora9 �-6 5 7-3 864 • T(Y 651-282•5332 0�Bpp•657-3864 � • � -�- . <br /> . Available in alternabve formats <br /> .._.. . ._ _ <br />