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06/08/2010 23:3? 7634975011 SPTESTINGINC PAGE 08113
<br /> �'arcel numher: ,..___,,,,,,,, ,,,,,, ,,,,,,,, System slatus: �I Complianl ❑ Nc�ncompli�nl '
<br /> . ...__. ... ..
<br /> (as dc�l��mined hy this fnrm)
<br /> Wydraulic Performance and O�he� Compl�ance - Complianc� Insp�ction Form for rxisting SSTS
<br /> Cpmpliance Issue #1 of 4
<br /> Dale of observa�ion: �-�.`�,��D�V _ Reason for observe[lon; �►5��.e i ���{ri¢:�,�-�._`__ _ ,_
<br /> This iorm explres upon next ins�aoction or!n Yliree years,whlchever occGrs(�Irst;
<br /> Compli�nce questionslcriterla: (Requlred) Verification Method': (Opllonal)
<br /> ____(Checl<lhe a�pronrlate box) ____.�, __,...---.-.. --_ (Checic the appropriale boxJ
<br /> Does the system dlscliarge sewege to lhe ❑ Yes �Nn � Searched For surface outlel IJc� '
<br /> .9:..,.__�..__.... e? .-----------T_....._............._..._..._...,,_
<br /> round surfac
<br /> ❑ Performed hyclra�ilir.. te5l
<br /> D�as I:he system rJischarge sewage lo draln I ❑ Ycs ❑ Na •
<br /> lile or surface weters7 � , �-SearGhed for seeping in yard�'�
<br /> Does thc system cause sewage bacl<up � ❑ Yes �No� ❑ Chcacked For becicup In liome
<br /> into,dwolling,qresto611shmenl? _,,,,___ _^__. . � Cxcossiv� ponding Iri soll system/D-boxes �1p
<br /> Do other sltuafions exist lhat hav� the �N.❑ Yes ,� No � Momeowne�testimony
<br /> potential io immediatc�ly and advorscly
<br /> impact or threaten public health or safely ❑ Examined for surging in l�nlc
<br /> __(olectrical, unsafc covcrs, elc;)?___.._
<br /> �I "Black soil" above soll dispc�r.s�l system �.l.q
<br /> Any"ycs"answer indir,ates that flte systern!s an immin�nt
<br /> threat fo public health and safety. 0 S�slem requires"emerg�ncy"�umring
<br /> �_ _. „ , .-------- _..�.,_..,....___.___ ❑ Perfiormed dye iest
<br /> Does the system pose a thre�t to ground ❑Yes [� No ❑ Other
<br /> w�ller for 2ny conditions cJoc�mcd non- ; "'-�"" """'" "—
<br /> frotockive�s determined by the inspeclor7 I _____,.,._ ._._.,,
<br /> .?�..... -. ....,._ ,—._ --•----....._.._� ,
<br /> "Yes"lndfcates that tho system is fafling to proi�ect ,__ ,r__ __ __
<br /> ground watcr. ff"yes", descr'ibe the condition noted:
<br /> "No standard prafocol exlsls. Tl�is list is noI exhaustivr;,
<br /> _�__ __.•- . -- � 1n aequentlal order, nor daes it indicatr•. wl�ich •
<br /> combinallons are necess�ry to malie this doferminetion.
<br /> Certification .
<br /> Tlils form is lo be completed and atta�h�d to lhe Summery Form of the Minnesota Pallution Conlrol Agency's (MPCA)Compliance
<br /> Inspectlon Form for Existing Subsurfaca Sewa�e Treatment Sys4ems. Ohservations,inlerpratations, end concluslons must be
<br /> cc�mplated hy an inspeclor. Complefed form musl;be submilted'to the local unit of government within 15 da,ys.
<br /> Property owncr name(s): ��1�fi ��}�_�,•S _,.� _____.
<br /> . Properiy acJdres�: � )� V��Q�r4� 'P�C�. l����.0...._....,_�,...,.._ ....-•-��•--�
<br /> Pfo(�erty ownc�r's address(If dllicrent): _ _ `_,.,�_.�—�_„
<br /> Gounly; �___��a�_ .�._, .,�_ Properly owner�hono: ��Z�,�1�p�I�'J��/' ---
<br /> I hereby cerfify thar 1 personslly made the ohsorvations, inlerpretations, and concl��sions reported on thls form and Ihal Ihey ar4
<br /> correcf.
<br /> �_..____._.y„___,. CerllTcallon number: (O o'},1
<br /> Name: ��iV��1_�..63.�...r51�1�4'.�'�_��. ....._...— �.. ...,.
<br /> busin�,ss licc�nsc name and number: 5-"ta��'�j��\.� ►�c. , �.�_(��3°j!�„y,,.,,.�4�r►��1�'.�3.,.5_�6 or
<br /> Nama of 1oc21 u it of govemment: ,,._..__ ...- ----.—
<br /> Signat�a�e: �;�-- , '� ��,.,.��� Date: •���.��e20�0
<br /> un�n�i�nr� �r�ra m,; ���� . F�+1-7QF�•r,�nn . ' Rf1f1-hR7�afllyd-._ . 'fTY R51•7R7•53�7 nr Rf)(1•l,57•3H64 • Avallable In all'ern�tive fnrmats
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