|
65/27/2011 02:21 7634975011 SPTESTINGINC PAGE 05/11
<br /> Parcel number; i �
<br /> -- �--- .- -._ ,,....-�.,.,. Systom status; � Compliant [� Noncompllant
<br /> � (as dQterrnined by this fomt)
<br /> i
<br /> Soflp Se��ra�io� �o�tn�liaR�a�e and O!ther Connpiq��nce- Comp/iance lnspection Form fo�'Exisfing SST�
<br /> Com�Aiance Issue #3 of � �
<br /> Dgte o'F observatlon: _�',�,���^ � Reason for observation; � / I
<br /> , ���������x.r�,_,
<br /> TFiis informetinn on this fo►m d�es not explre. � —•--'
<br /> Compliance qu�stions/c�iterp�,: (Requi�ed) ' �ex�ification Method'"'• (Optlonal)
<br /> _(C6�ec/�fhc ap�ropriate P�ox),
<br /> --. - -�� .a�_._ . (Ch�ck Ihe appropNefo box)
<br /> For systems bullt prior to April 1, 1996,and not
<br /> located in Sh��eland or�NellHead Protection � � �onduct�d sofl observation(s)(aiiach boring lops)
<br /> �Area or not serving a food,beve�age or ' ❑ Two prevlaus venfications(aitech bc�ring logs)
<br /> ladging estahlisl�ment: ' � 7 �
<br /> � �ther. .�•��:,_.Z��_5'�:��.�7�f
<br /> Does the system have at least a two-foot � �n - --
<br /> vertic�l separation dlstance from periodically � _"��1l�'���:�-"�`"t
<br /> s�turated�oi,l_or bedroek? .„ .._,_ �Yes .,� No _ ��,���,5_� ����� `
<br /> For non-perFormance systems bultl April 1, I '
<br /> 1990,or lat�r nr for non-perForrnance systems �-�"-- -��� - -••—••-�—
<br /> Iocated in 5horeland or Wellhead Protection � Soil obseruation does root expire. Previous observations
<br /> Areas or seiving a food, bevorage�or lodging � by hnro independent parties ere sufficien�l,unl�se sitQ '
<br /> establlshment= conditions have been eltered.
<br /> boes Ihe system ha�ro a khree-foot vertical �
<br /> separaiion dist�ance from poriodlcally saturated �
<br /> .soil or bedrocic?" Yos ❑No �
<br /> -- - �- - . —._., _�.._.�,----,.._
<br /> For reduced separation clistance sy�t�ms(i.e.,
<br /> "performance"systems under old 7a8D_0179 or I " IU7ay be r+ed��csd by up to 15 pem.ent If allowed in local ,
<br /> Type IV or V svstom under new 708U.2350 or o►'din�nce.
<br /> 7080.2400�; ''"Mo standard protocol 9xists. Tlils list is not e,d�austivc�,
<br /> Daes#ho sys4em m�et the designed vertical (n sequential order, nordoes itlndlc�t`r�which
<br /> separation dfstence from periodically satu�abed � combfnet►vns are necessr�ry to m�ke this
<br /> . soil or bedrocic?* . .�J.Yes No__ d�terminetion.
<br /> A►ty"no"enswer indicates that tho system Is fa1lfF�g to proMr.t �
<br /> g�'ound water ; �
<br /> i �
<br /> I
<br /> Certifacai:ion
<br /> This For�is to be cAmpleted and attached to the Summary Form of the Minnesota Pollution Conlrol Agency's (MpCA) Compllance
<br /> Insp2ctior�Fornn for�xlsting SubesurFac�3e�nia�e Treatment Systems.ObservaUohs, interpretatlons,ancl ca�cl��sions must bo
<br /> completed by an insppctor or designer.Complete�form must be submitted to#he local unit of government within 15 days.
<br /> Property ownEr name(s); ����p��Q��✓�V�
<br /> ..,_�._ -----•.........:...... _...,. ---•,.__.. __., _-
<br /> P�operty addr�ss: �a l�(7_ _L�-�..,__G'�rG'�i1G'�'�, p �S,
<br /> �' , . — - _r,_ �_v....._.- -- -.,_ �
<br /> ..
<br /> Property own�r's sddress(if different): _.
<br /> ..,. _. _..._.
<br /> _......` -._.. ,._
<br /> --,. __.._ �
<br /> Courrty: ��.��..�_r`i j�„�..,., i---- P�operty owne�phone: Qf ,�2^ �' �
<br /> �. - __-��._ ..,g,2�__ _ �
<br /> 1 hereby certlfy that 1 personally macle Ehe obsolv�t�ons, inierpr�tations, and conclusions�parted on this lom�and that they�re
<br /> correct
<br /> Namo� '
<br /> ...r�{��'�'��f-,� f'`�. �.�L;1�a 1_- ' " "'`;_._......_.. Certificalion nurnber: � � �
<br /> _...._- .-.�rl.�...,----�• -
<br /> , • —_ .�
<br /> B►,isiness lir.ense name and number: _�,-,Q�r�y��,•� ����„y_��� �„��`�'�,�j� �,��',����J�=�`r��.�,. �,,��� � ��
<br /> Neme of local unit of.government; ! �
<br /> i ..:.....--- ....... ---...... _........-----
<br /> , . —•••-•. ••--- ...--- �-}
<br /> S�gnature; -r, r.--1 ; �
<br /> �--e
<br /> _....... _.._. ... .-- --•-��••--- -..... Dete: �a_:�"�a01�....: I
<br /> , �
<br /> —....... __...,..... _. ..- --......._ � _... _....__ _,,..� ... _,..,_
<br /> www,p�a.st�te,mn.us • 651•29b-6300 • 800•�57•38h4 . rrv R�t_�R�.Fiz��,nnn.c�7 �ocn . �.._,�_��_ :_��_�„ :;—'--
<br />
|