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�7/13/2010 02:07 7634975011 SPTESTINGINC PAGE 05/09 <br /> � �. <br /> _I'arrol number: � . <br /> _ ' � •-•--• -- -• -- • ---•--- ._.__ SYstem stalus; �C��npliqnl f]Nonco,�pilant ' <br /> (as de(ermined hy rhts inrrn) <br /> Hydraulic Pertormance and Other Gompliance - Compliance /ns ect' <br /> �ompliance lssc�e #1 of � p ron Form for Exisfing SSTS <br /> Dale of observ�lion; <br /> —�=�=ap�� Reason for observ�tiort: <br /> 7hls form explres upon next Inspection or In three earg, ���-�-���`� <br /> Y whichever pccurs firsL• ' �—�— <br /> Comptiance -------� `� <br /> questlons/criterla; (Requ;red} � —"` <br /> ___(Ch�cl�fhs anp��fato boX��_� Veriflcatfon MePhod': (OpHona()��_�^. <br /> D�es lhe system discha e so_ � --' (Ched�the a <br /> .�rp��nd surface? � `"'a9e fo the � ❑Ye^. �,N� Ppn�prlete�x� <br /> Does the syslem�fischerge sewage Io drain � � S�arChed f��surfacp oullel <br /> —����_`� <br /> «�e-��r sur(ace water s? �Yes ❑No ❑ Ferformad h y d r a u U c t e 9 l <br /> Doeg the systerlt rause sewag.e vaCku�PS-� � � Sear�od f��9�pi�q�n ya�c1►.Ip <br /> int—°�o��t.ng or establis��mQ��q���� � No� ❑ CheckPCl for bar..lcup It�hc�mo <br /> f�o olfier sltuatlons exlgt Ihat lteve Iha � � Excasslve ponding in soil systnm/b-boxas�•t0 <br /> potenllal Co immediately a���g�,��e1Y ❑Yes � N� <br /> impacl or q����en publlc hea(th or safeEy � �. HOm''�wnar lasiimony <br /> _�electrice�,t,nsa�fP covers,etc, � <br /> - f_7 Examined for�eury;n9 in lank <br /> Any�•yeS��a�31Yer/nd/cates(hat tl�e system is an/mmin�- 1� <br /> t/ireat fo p�b�����Qa�th aryd hA "Black soi1'ohove soil <br /> �. sa�etY� dl9pt3rsal systerrl�y,0 <br /> —�-` [] Syvtam requirns"eme enr. - <br /> Dcyes the system pose a thre2t to�—� ""' � .y pum�ing <br /> water for any condipons deem�^o�und Q Yes �,No � �'erTormed•dyo test <br /> �prntective as tl�te�m��ed h�e�Rg eCtor? { ❑ �ther. �� <br /> ..1'�5"!ndlCates[haf�Q System 1�(�j/�n to � <br /> grot.rnd water If"yes", descrihe fhe Co�,tt���ed: ~- <br /> __ _-- . --'_--�'"_,— <br /> __ ' — ___ � "No s�and�rd protoco!oxlsts. This Jist!s nor exhaustive, <br /> • —_. _�_ " . In soquQntra/orrJer�or does ll!ndlCate wl�ich � <br /> —�•��_ comb�natl�nc aro neGessary ln malie thls delcrm/nafion. <br /> Ceftl�lCdtlOn � ' <br /> Thls form Is to be completed and Ptt�chacl to the Summary Form oF the Mfnnesota p����; • <br /> InspecUon F�m�for Existing Subsurtace Sewage Treatment S tems. <br /> Complp���y An insppClor,Com letod form miist be suhmihed'to Ihe loCal unit oF ov� ton Cont�p��9p���g(MPCA)Co��p�lance <br /> p Ys Ohserv2tions,inlorpretatlons, and concl�,slp�S�,Ust he <br /> Frp en � 9 rnrnent withtn 15 deys, <br /> P .Y own�r name(s): �d�`��� <br /> Properly addrQss: ���b FQ� ��-��,/ �' —�_.�. <br /> PrD eR �`-�'r�'"�---�--�0_ •.�L(7 ~^ "�."--•�-, <br /> � y owner's edcJ�ess p(dltiernnt): — - �- <br /> COunly: ,�� —"—� . ---,�__— <br /> ��"—�• ._ hro�ortypwng�— Ph` ane. AUb• --� _ <br /> f hereb .�_q�2;,�-��'Z.D7 � <br /> y cer(ify Ihaf I pPrscma�� mano�he�bseNallons,/nte refal/ons, and conc-Jusi�ns� <br /> corrocc. y �p . —.-�._ <br /> Pculed nn this forrn and lhat they are <br /> Neme: ���Lr'G�.��Ij��Li� . <br /> susiness license name and.number: �``- ' Cerflf►cation n�mber. _(���__ <br /> �•P'��r.�1�1���� � <br /> Name or iocat u_r��t of9ovemment: � -`�a'�"'�-�1-r-� ���,�-�g —"` <br /> Signature: ��.-�_ y . • • `2�'�`�- _ or <br /> � --,---� <br /> . � ---_ Qate: '�< <��� --- <br /> . . �_ <br /> wwhr.pca.state_�ci.vs� �• b5t•296-5300 • � 84p-�651��$�� . <br /> wq•wwlstsa-3r • 4!TOlQ9 , � 1�Y 65i•28z�533�nr 800•657-386�1 • Available in altemative formars <br /> � '� ' <br /> . , Foge 2 o f 8 <br />