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07/13/2010 02:07 7634975611 SPTESTINGINC PA�E 04/09 <br /> � -� <br /> _ Percel nilmher: � <br /> . ._ -- <br /> , �^� �� --- � -.---•-.-,._. SYstem 9tatus: ' �CompllAnl ❑NoncomG���nl <br /> (as delermingd hy/li/5 IormJ • <br /> Soif SeparatTon Corr� <br /> pliance and Ot�er Compliance- Comp/iance lrlspection Form for <br /> Comp(iance lssue #3 af 4 <br /> Data ofohserva���n: �Xlsting SSTS <br /> THis info�maflon on Ihls h�rrn�` ���� -- �eason fpr nhserva6on_� <br /> daes nol expire_ <br /> ComplianCe ' �������� -- <br /> �ues(��ons/criterie: (t��uired) ��� <br /> _ Ghock lho�p,n ���e�ox�L <br /> ror systCms bu11t priar tq/.� �� ue�ificat'lon Method`�;(pPponal) <br /> ~�� -"� (Check the a <br /> locate�l in Shorelsncl or We Ihead�P os�hnot I Ppropriate 4oxJ . <br /> '4�ea o�nnt serving s food,beverage�r I <br /> � Conciucted soit obgarvatio�(5�(��ach bori�q��5� <br /> 1oc19�ng est2blfshment: <br /> Does.lhe S $ ❑ Two prpvlous veriflcallons � <br /> Y tem have a(Ieast a two-foot ��«ach noring Ir�q;� <br /> vertiCa�separg�ion dfstence fjb 0 �=her; ����� <br /> _�ahrr?ted s„oil or bedrock? m periodicallY . �„�g��� <br /> Far no�_ � -�..— L]Yes q No -��-�-�'-���L��^(�---� <br /> Perfnrmanr,e syc�ems buil!April t, <br /> 1996,or leter o�fnr nq�.pe�rtttance sy�temg , ���-�lr�A�1�`$_�L1 <br /> lOC'at�'4 ht Shorerand or Wellheah I'rot�Ction ����� <br /> Areas or Servin ' . . ��"�_ . <br /> estabi�9hmont: 9 a food,heverac�e or fodgfng ' SO1��dseNaUon does not explre, prg��o � ~��- <br /> • by two indeK,endent art(es �' °b�wations <br /> Does the sys(em hava a thre f � • condltions have►aeOP a��eredre eutll���������oBS <br /> seRaraCon dlstance f�n �°Ot�°n�cat 91�� <br /> S-_°i�J o�bedrock7' m�eriodfcaily S�lurated � , . <br /> � �er r�d�Ced sepatac a,1 dislanc�systsms•(I.e„ Yes Sj ry_� • <br /> ance'systems uncler o!d 7080.0179��- <br /> Type fV ar V system under new 7080. 7350 or <br /> 70$p.24Qp); ' May he reducod hy un fo 15 percenf if altowed <br /> �oes tho s ord/nanr,E. /n loCa/ <br /> yslern m�,t t�e desig�ed vertical �'No s�andard <br /> sepa�tion distance from�eriodfCall in svquent/al prtJe��D doesttrindlSr is <br /> Sot�or ix�d�o�kti• y saturated �o!axhauylrve, <br /> Any«ha.. — a+mb/nalions arQ noce$sa ��e whlch� <br /> e�swer fndicates tha[t Y�� N� Uelermind/ip�, �'ro make thic <br /> 9ro�nd wafer. ���yster►�Is fsI/ing lo protect <br /> Certificatian � � � <br /> Thls form Is to be completed and atfached 2o the Summa <br /> IttspeCtinn FoRn for�xlsting Su�isurfa�o Sewage Treatmen �f tllo Minnosota P <br /> COmp�e��by an.in�per,tor or dogigner,C�m o11i'�On Lontrol Agen S - <br /> pleted forr��ust he subm�itlod o tlSe I c I unl!o�f m�tatlons,a d tconclu5ion.c�m�t bP <br /> 1'!'operty owner name(�): govemment with�n �5�2Ys. <br /> Prapert a �a-�"�4� ��' . . <br /> Y ddress: . 1�� — �y__ <br /> Property owner's addrEss(1Ldltte�O K� � / . <br /> D._�p <br /> Counry: ~ . �� --,--.— `�� <br /> . ' �` <br /> "-------.�_ Properly ownar phone; -','.�`�,—�� �,,�. <br /> 1 hereby cP��y lhal/pQrsona!!y mado th@ QbseryPlions, � ���`�Z`��=��� <br /> corr�ct, terprelafians, a � <br /> nd Concfusions re � -~` <br /> • PO�(ad on fh)s forrii and thar lhey a� <br /> Vame_. 5.���,�_ , „ �� - <br /> ,�L�4�.�, <br /> 3usiness IfcPnse n2me and number. �``L� Cenis�tl�n number. <br /> �ame 5..�'..����l�a � --�� <br /> �t lpcal un�ovemment: �--��-�--�-. . --- <br /> >Ign2lur�: / ��7.�.�.�=���7 - <br /> �Y i.��r .. ---��(r�---`_ or <br /> '--�,..__.. <br /> . . �--� Date: �_-'(o-'?�LQ_ —� <br /> � ---� <br /> n�c�r.pca.state.mn.us�• 651•�96�r7g0 • $00-657•3gbq • TT1r 651•283-533Z o�.80a657-3864 • qvailabie In alternative fotmats <br /> wq-wwists4-31 • 4/�!0/09 ` • <br /> � � • � � • �ge 4 of 8 <br />