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12/05/2007 26:45 7634975011 SPTESTINGINC PAGE 04107
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<br /> ' ' 2/Z5fOZ ' Watcr/Wastew,�CcF�STS�}.a7�
<br /> �� �o�n�api rn��.xn��pe�ibn �=o�rlr� fioA' �is�ing � � .
<br /> In�div�l e�a� ��wage�"�'re��ment �'S�eA111s �9nnesota Powlut�ore
<br /> �„�,�.- . . • Cok�trol/�gency
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<br /> Compl9Uor�of thls for�1 fulfllls the rrilnfmA r�qulrements of Mlnn,�tnr,§ i 1�GG(20oy)�and Mlrn�esota R.ch. 7080„{f 999j. Piease refer
<br /> [o IocRl ordlna[�oo�fo[ci� er re 1�ltldhls prinforiTtOtfon es .ecl�il r,+com•Ilance re ulremenls.fo�beqroom addlflons.
<br /> Gener�il:� ' � � ' � . . ,
<br /> Daxe vf�r��pection: 1 I��,-'u"7 � It��sop��nr ins�actian: �,�ryy��� '('_��'�'� •--
<br /> �ro�erLya�nr��er(.$) ��Do�..l, •�'��t�l 'I�ra1_� � 'x'eleRt�one (9��,1-'y�9 - d�6i�
<br /> IPo�s�vn req�resl�n�r Ir��netk�ora '�.� 'P��'Q;S � Telephene (�.n-) �a�0� �SSS
<br /> sike,�#dclr�ss 4'�� �u�;�-- '��SS ' . •C�t�' _,o�P-c��.� � � �iQcpde �
<br /> F�i-e I�lo./ 9�arcel INa - � • Coul�tlt�l.�k'�.l�Ptil.s� '�'c�lNrwhip • �
<br /> I�gal Descriptl�on � � —-
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<br /> �.oc�l Regu�at7o�/Autl�ority�_ r�tr' 0"�9!-+�c7
<br /> p�1t�sy�L�em constKuctetl' R��� ��q� c5y�k�m��S��i�r�aiand Area: yes(� SXstem in 1MeI�F�ead
<br /> PraL�cl•ion Are�: yEs i� 5�/s�m�enring�a INpH�ic�nsetl'fecAlily; yes (�Local���Ir�x��t# (9F any)_._ .
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<br /> �� Sysl'ems�uilt prior tn Apri.l ;[� 7.9�6 �hcl��at�oGated�n Sy,st�ms'loc�ted in Sl�oreland;or Wellhead,Pr�otection
<br /> Sl,oreland or WEilhead Protectivn�I�r�a or Senring a�Fdod, . Areas or SeMng,a,Food;Beverage vr'I.odging
<br /> � Beverage or t odging �tabpsl�ir�ent• • �� �rCabiiShtnen�,or sjrsteTn5 F.►Ullt afCe� .
<br /> ' ' ' Mar�h 3� f99G
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<br /> �s U�s�s�et3as'�a.1I1�;�ICM]9.[�¢nt thre��i�a oublic healll�b'r, Ts�tlie�sys�g�,L�,�nen�threa�to riub,J�,c iealth
<br /> �a��t�(a yes ansrv�r Is an.i�FFH��m).', ' �s t'a �tv7,(a�y�:s ansW�r�s an.T�'PH,�syst�m) ! -
<br /> -Discl,arge of sewage to t�he,ground surfate? YE5 IVO -Dlsdiargc of'sewa�e to tlie ground s�I1�fi�eP X�5 �Q1
<br /> -Dls�hargc vf��wage lv dralritlle or�rfaCe wate�? Y�5 NO ��Disc{iatga o��sewage to drAintlle vr sur�ace v++�tcrs?YES
<br /> -Sewage bacicup Into dWellln�7 ;. � .�1F�S WO �Sewa�ahackup Inpa�INrelqng? iY�S �
<br /> -sr�i,a�ion w�tli lhc pol�nUal L'v Immcdlal•�ly and ' � -�l�a�lon willi t•he poi•en�Ial to lmmedlately and • •
<br /> aciversely impacl•or threaken pubrtc health•or ' � •adversoly Impact vr th�eate�public hralth or � �
<br /> Saf'eLy? I , ' YES NQ• safety.7 . , . • . YES �
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<br /> xs t�e s sy���fiajlina�(a,y�s ans � rl.�,a f�tl�ngsyst�rhJ Zs tlae svstd�ri#aili�ct�' (a yes�srnsw�ris a fail/ng sys�`emJ .
<br /> �I.ess q��l�`�'�1►a f�eet of vertl�al,separ,ativn be�en� � . -I.ess l�ian•�I'HIFtEI��'�eC ol`Nectical•�s�parat�on•betvVeen
<br /> syst�om•botkorrr�ahdsatUraL-ed soll nr�ti�.�drbcic? ' � ���'Y�S ��I�10 •�sl�rh boi�ot�arid s�lur,3l�ed soll or I�edroc{c'� YE.S �
<br /> -A seepage plh,cesspool,dryWcll,or�(es�c�iing pll7 • Y�'S�'NO -A3�dpage plt,ce��;,pool�dryWell,or leathing pit7 ' ` Y6 I�
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<br /> Ts_�i�,o�st�m�,a��comolianL'� ' • �5#�e_�v�t�m�hvr�-coenpliant3' �, �
<br /> -•Is the system regulated•undgr a mo�Ro�ing pl�n o� � �� la the' systerij-regulated under a.monitorin,� plan
<br /> onerating permit? ('�f no,.go�o page . YES NO " ,opecatin�g po�rnit?'(!f no,,qo�page�2j ' Y[S �
<br /> If ye�, � , � , • lf yes.• ' , . .
<br /> -Fia�ihe r9quired monitoring tslcen p�ace? � Yl-�• NO -hlas ihe req�lred monitoring talcen place? • Y�S N0
<br /> ,(�I no, the.s�r.srem 1�nonrcomplying) I . � ' (11'no,�he•syeCem Is ncn-c+oirm�lying) •
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<br /> -L'1�es.thr�moniloring Indtce,te�hat th�;�yst�m me�ts ••� =po�;+tKe mo�iForing indfaa'l�th�lt�lre system meets
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<br /> @erFol'rt���ica expectations�' '� � - �° • , `�"YE� ;T10 � � pe1`f6tl,ne�rs�eM ectak(o.r1s7 � YES� No
<br /> ,n � .� . .i�..: ' ��..• •'ti� ' r:�' . . � ;, � ..��•: . 'I .� .`f� 1. �...�. .. .n! �. .. . .. � ��, ' .
<br /> .(If�no, :tf�e:sysf�m Is•non-cbmpJying) . � • (/f no, fhe sy'siem�7s nan-complying) �
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<br /> I P�gc �. of�2. � " wc�-wvvis�h.31 � '
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