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� f � �i�.:;l ii ��:.,. _ � -------_ S�,sr ��.��a us. �� Corn�lian? U Noncompliani: —------------ jas deternlined by fhis form) �fAE� ��,3�=1�'r."��a�.' r ;"�9r�.`��, �a '.��2��" �3�9'�'�„��V'ls,=. a., .Y,: -�.3i.��v� 9r� ✓'�P .. Date oi obseniation: lt6J `/Qp p Reason for observation: _ This informatian on this form d s not expire. �Q��piiG;7ce�ues�iCr;s/c;'iTe�'ia: (Required) 'J�;';,i��'iion iVfei'itpG"*: (Opfional) Check the a ro riafe box — �Che k the appropriate box) For systems built prior to April 1, 1998,and not locaied in Sho��land or i�lellhead Protection Conducted soil observation(s)( � Area or not serving a food, beverage or �T�previous verifications(atta�s�ir�� lodging establishment: I ❑ Other: �f'eQ0 Ou�°O�t�— Does the system have ai least a tvvo-ioot I « J � vertical separatior distance from penodically �__ T�___ saturated soil or bedrock? ❑Yes i�lo • For non-per�ormance systems built April 1, �J� ��,� 1996, or later or ior non-perfonnance systems I `��J—�"�" � _.��--3-��— located in Shorefand or t/�lellhead Protec5on Soil observaiion does not expire. Previous observations Jareas or sen�ing a food, beverage or lodging b;�tvvo independen,parties are su;iicient, unless site establishment: conditions have been altered. Does the systern have a three-fooi vertical separation distance from periodically saturated ; soil or bedrock?' __� (�Yes ❑ No For reduced separation distance sysiems(i.e., I "perrormance"systems under old 7080.0179 or I " May he ieduced hy up to 15 percent if alloaved in local Type I\/or V system under ne�,v 7080. 2350 or ordinznce. 7080.�400): `"'IVo standard nrotocol exists. This list rs noi e%haustive, Does th�srstem�ne•�t the designed ve��tical in seciuentral order. nor does it indicafe vvhich separation distance from periodically satzrrated comhinations are necessary to make this soil or bedrock7` I ❑Yes ❑ No determin_ation. �,ny"„�"a€�swer irr�'icazes�'hat P1�e s_�sie;»i�failir,�z io n�:�ie�t �.,,0`rliC� _�,.�,. a..'� .. . __ �.�.:i This form is to be coinple�ed and attached to the Summary Fonr ofthe NlinnesoYa Pollution Control Agency's(MPCA)Cerr�7ii�_;�c� ia g :o ::tO.' _ � 'i !C : JS:d:14 L�'�::3:'U :aC�:�a�i^,`;? : completed b, an inspector or designer. Comple�ed fonn must 6e suamitted ObsQrv�cal�nitnof govern'meniavi�thin 15`aay5s must be Properiy owner name(s): Property address: �/�� .."^jLC�c _�� -- _ ----— --- Propeity ov�✓ner's address(if different): Count��: �.�v Phone: I here6y certify that l personally made the obse�vations, interpretafions, and conclusions reported on this fonn and fhai they are correct. Name: �o ,�� Certification number: �J,4 Business license name and nu�nber: �L�j,,q !v dS r' r�, -��- - ---- �'zJ _- - °'� Name of loca� �mit of government: �,� �(j� Signatw-e: Date: � - �__,�_ �•_o�____- wq-��,visis4-3i Con�tiar-,ce(i�lspec�ier,}-orrnjor Ex,tstii�; SSlS 9li108