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FF20hl : Paatasontc FAX SY5TEP1 PHONE N0. S 612 753 6222 Deo. 11 2012 11:17Rhf PS
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<br /> Parcel numb�r. .�0-1�7-2�21-0a06 ,,,� system statuac �compNant p Noncomp�ant �
<br /> � (es dete�n�lned by fh�lorm) '
<br /> $oi{5ela�taticn CpmpH�n���nd O�h�r�qmptlan�� I
<br /> Compltanc�lssue#3 of 4 � j.
<br /> t�te oloba9tvaUcn: 1?,�/8�J12 ,,, Re�soA fa obsetv8lkm: PoIM bia�lo ,.... .,,...�,.
<br /> rhle Intormatlon a�fhis lorm�aes t�at expJrg. �
<br /> � Compllanc�qua$tlons/o�iterla;(Requlrad�. Veriitcation Mathbd'";(optiona�
<br /> ___ _(Check the approrNl9ts b4X) (ChvpJ(tt�e spplaptlale bax}
<br /> For eyetome bu�t pdor to Apr111,19fl6,and nat : � Con�Woted sog observatton(s)�altaab Ba�ind Icne)
<br /> ' focated in 8horefand or Wetlhesd ptoteotlon
<br /> Area or not�ervinp e fooa,bBv�sr�o or � G 7wo pt�ous verUkxdans(atteoh bodnp Ioga)
<br /> Iodeing establtshmen4 � 4��� ��
<br /> fJ08B NIA 6y6fAtn lypya a��88819 fW0•tUO�
<br /> vo�favl sQpara!!on diamna�e,from Perlodtcdlly --��--��-------
<br /> ��f,¢�i 649 or bedrook?�.� Y�s ,�{o_, _,,, ..�.
<br /> Far non�pedormaraw sysiema bufikAptfi 1,
<br /> � 1996,or Iatei or for nan-pertwm�nae eyetems g�t����� ira Prevbue obsant�fians
<br /> looeted In 8hcrefarui or Weilhead Proteat(on b hyq In�apvndent �1�a sufflcl�nt,unlese 6fte
<br /> Areqa ar aerNng p food,baverana or tbdginp oondAlone hs►w b�aRered,
<br /> wtablishmonk
<br /> p09s tho Fystem have a i6ree-fnM verflCat '
<br /> ses�araaor►�stflnCe from periodk�i{y estutatee ,
<br /> 8011 or hedrooR7` ,,,, Yoe
<br /> Forraduoed eepnretton d{sfance aye tems(l.e.,
<br /> �pe�ipmkuio&'systeme wider�d 7b90.0979 or ' MaY be►eduoed by up fo S��aohf H xNNowotlln lacnl
<br /> Type IV or V system under new 7Ui�o.2350 nr ' adlnan�e. •
<br /> 7aaoa'�oox �ND 9(krld8f(I p/W000107lJStS.ThIV IIA�/81JOf 9XIIBu6IJV9�
<br /> p06s iha'system me�t the designed va�looi �►8�1�M��►��,nor doea i�lndkntn wltbh
<br /> sgparaUon cltetence frwn pertod[caIly setp�ated �ndln�neooaesry to make IhJa
<br /> so8 ot bodrack7' Yes No ,
<br /> AnY bno"apet�el'lnNloates tl�$t fho�yetolls!s ti►ll�ng to proLoat
<br /> �round Wa�at
<br /> Gertificaxlon � '
<br /> 7his famt is to be com�l0ted and sttechad to tha surnm�uy Fc�»pf tha M'iAn�eota PolluHon Controf Agonoy's{NIF+CA}Cornp4tnnav
<br /> 1»sp�ton Form tar pxi�ting 8ubsuMa�e�aw�'gg Trffet���n!sycEemu,Ubseivalbns,Interprefatbns,and cn�tiCiustons mi�t b�
<br /> avmpbted by an Inspector or daslpner.Comp[ated fann muat qn submlRed io the 1vca1 unR of g�v�mmarit v�htn ib days.
<br /> Afopetly ownAr r�me(s} Fldelity fes�Qgtf9�e t�Ca�sy,��A
<br /> _-.�-�,.....
<br /> propeny addrese:15 Frenat�Leka Rc�d,ffr000,!AN 85$p9 .� �„_
<br /> P�op9►ty mmer's nddtess(If JUferonq: 820 Jr+oHspnvtlie Rt�d.8��,1,t,a t�2p4.Wermindk.pA 189Y4."�..��
<br /> Couniy, Hennepl.n w _. . p�one: NA „�� - - (
<br /> 1 ha'oby ceHily thot 1 por�aruby tnc�da tilb obeervaUars,lqtorprdtetMns,ar�i condnafons►oported on ll�t�fon»a►td thDt they sro E
<br /> oOrrnCi. • �
<br /> 1�emq:• Mark'lYtiQewell 4__. Ce�tl@owk�nnurttbar. #2�oe ' , �^
<br /> 6usinasa llcnns�name end numbar. �' dowol S,�il_rQaUn$#3U9 ar �
<br /> t�a�,o oftocp►unri nt gover enl: Cii .�� ��
<br /> s(gneiura: �rt�.�.rC��.,..� . Date: 12106li2 ,� • . .
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