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12/05/2007 26:45 7634975611 SPTESTINGINC PAGE 05/97
<br /> Prvp�rLy owner(s) ��YV+'�c�l�'1 � Rire No,/Pa�cel Na. ...
<br /> ...,.............._._.�............��.�.....����__��...�......�...�_,_._....,,...._.,.,..._.:...._.r _..,.. �
<br /> s,,,�rstem Gomaonent� (P/ease descrf6e t�ie sys4�m�c�mponenC�r�rid e[#�ch slt�sk�t�i show�rig,,y��in%acation�;
<br /> . S��'`'��v�l �a�.s�s��'s o� � s�c.-n4��v� . PU�� ��►.1���� ,�.t,�� . .
<br /> '����_�a�za� r�►.o,a�,..� ���1��� i.Uti-tl� 1��v � �t � ��.tc.�;�'
<br /> . ,
<br /> . . . . . , � .. r�. - -
<br /> � � • �- . , -, . . , .�
<br /> 1NhaL•'�T�oF,��ods ware used_M malc�the_datartnlriatlons for L•he aarr�p,��rg Insoectlon�(Nat�.'No.sl�lnda{n'protdc�/exfsts
<br /> Tl�e�y/awinglJ.si`lsnotFx/�ustri�or/n s+�quenG�/oro'er/�w�Aid/c.�l�s��hlah rnmG/n.�tlau'mayne�c�aryto make a del�iminatroq)
<br /> . , .
<br /> Wa1:eN:iqh�tank(s) I�Iydiraullc Punctloning � Verllcal Separa[iott qisCance
<br /> � t�robed lank bolhom, � Searched T�ot surfice outl�fi � � co�ducked sofl boring,
<br /> ❑ Observzcl low liquld level . o� .Pertormed hydraullc LesC , Depbi to(lmitlng layer.1•���3�
<br /> [5 6camined const.re�ords e�'� Searched for•sEeM�g(n y�rd'No Depd�to system bottoir i� � �*a.'�v�.�.�,
<br /> !ob E'�camined empty(pumped)t�nlc o Cherked f�r back up.ln haine a �xamined r�corcls �•3'�3.��
<br /> • • �p 5�4���
<br /> ❑ Prabe.�ou�tde tzinlc far"blacic soil" � Gccesslve ponding In sol�syst�m/ti-boxes O 'LGU L1mltiqg l�yer Verlficatlon - ,
<br /> ❑ .Pre.ssur.eJv.�cuum check � a Homeowner restirr�eny •. - �a Othor
<br /> l� Ohher ,_; O 6camined for sWrging In 1�nk
<br /> '�Y�'�'4'� 'S�'�(•'F"�'�t^F��a�.l, ��, e "BlacksollR abave soll syskem'��u, .
<br /> � q Olher . . .
<br /> � ' us, f t � �em , •. __
<br /> . . . , . . . , . , . . �
<br /> ��sed o�i�I�e�cvmpUance crtifier�a,fihe�9ystem sl:r�tus ts� (check ofiea ;O �Fa11in5��(to ptvtecb groundwal��) p an '
<br /> � � immineqt�hreat�o public h�alhli or safEty(I?'PFIS),��C1 nari=complianti(monilbrlrig issue) �t cbnipli�nt'(none of the 3
<br /> prevlous contlivans). TheFeCare�.thisduauiinent is a: L�I'.C�rtificate oF Com�allance ❑.NotaC�a of Nbncorat�llance '
<br /> �s ihis •em�ari'CPI�Glas�"1I`� "e�tlon We11�7�, ❑ es ❑ no ' , '
<br /> ' ; . .
<br /> ��rt;i�FiCatian, • . .. . , . , • , , • ,
<br /> �
<br /> I,hereby cerrlfy as a st��te of Mlhnpsot•a IltGnsed•Tnspeclnr and/or Deslgner I or Quallfied�nptoyee Inspeclnr an'c1Jor Qualified Cm�loye�
<br /> �eslgn�r i�,ak i canductecl an Investlgahlon tiiak ac�wr�tely deCermined the compllance status of tliis syslem and th�t my recor.ded
<br /> olasservallohs are accuial�as o�lhls dat'� •�No determinatlon.of future I�ydraullc performanc�has been nor can be rnade clue l•o
<br /> , unla�own candllions during sysl'cm cansl'rutGon,abuse of U�e sysrerri,lnadequaFa:m�fnCenanr�,or future water usage. .
<br /> znsnector's name(printa �'��1,'�.� �,�, °5 �U 1-l�fi�vtti•��� Phan�� ^ ��!,t- 3�(cr L ,�
<br /> LlcCi1S�and/or RegiSl:�Uon Numbeh ��)� /uldt�ess 9,�'L ��l�S`'��L"� L�Q• �I..l�, �
<br /> �mplo,yerJ bY � � ' Addr�ss_ _ � e �1.L
<br /> �. . Gb��4'�P'C.� �'1�. `� ��„.
<br /> Slgnati.n'e �� � ^��—�—� Date�i��2..�
<br /> '
<br /> Uoarade Revuir.�etnents ,�de�d�nmMlnnesntaS[�a[ril�s�,t.t�::5�) �
<br /> An,1TPKS mus(�hc upgraq'ec�mo/a�d,or/L use dlswn,dnued N�thln ten monbhs Gfre�e/pC of thJs natk�or W/�11lr1'a sharter.p�eriad it'
<br /> requli�d by/eca!oMlnance. IFt�ie sy.�l�in fa!!s ro pVvv16!e su�lent ar�undwAtc�rpro�tla� then�►ie sysc�m mi�stlae'upgrade�d
<br /> replaced, or/is use dis�nD►nued wltYiYn�i5e pme l�equl�d�iy�rv/e o�:rhe�a!ordlnanc�. Ifan exlsbng sysCem/s not fall/ng,as def/ned in
<br /> /aw,,and/�as at I�st two�'eet of de,�gn stills�p�aratlon,dien dte sysC�m nc�d notb�u�gradeq;nepa/r�d,�ae� or/�s use
<br /> disrnnNnue�d nr�l�isianding any Ixa/o�dfnenc�tlial�ls more sYr/c� 77ils b►oe,s ao�app/y 1�i sysCe�s Iri,s�iar�/and ar�s, we/lhead
<br /> prol�on areas, ar.lYiose r�se�dln cnnne+aYon w!!Y�/bp�laeverag�,ah�/adging�W/s�imanlsris deRnedln/arv. .
<br /> Suqaested , t�c�meni:s , .. � � �
<br /> 1� '"Slte sf�el'th could�also Include:well,wall setback tp�i,�m,dwelUng or oth�r bulldings„t�ink(s);reserved soil��atmen�area,
<br /> si�ifaca'w�{er and�§cll boring loc�tlons. Tnclucle�s-bullC cliawing If ava(lable. ' � •
<br /> 7) Soil boring lo�s, 'shawing each'horlibn.`Irldlcat�th'e'�exturc,colvr,redmdmorplilc Features derkh•tb bPdroclS,staiicling waher and
<br /> whehl�ec the m�lEtlal Is�111. ' •
<br /> 3) A Ilst o�any,and all requtrements oFthe,local ordlpance thaCare silPhecent fi:om Li1e s�il�r,equiremants i�Pcrred tti on�I�ts form,
<br /> 4) A hameowner survey oF system peri'orm�nce�slgneci by the homeowner�,^being f.actual. •
<br /> S) Monil-oring data as approp�iate. . '
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