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03/22/2611 22: 49 7634975011 SPTESTINGINC PAGE 04109
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<br /> Parcel n�.�mber. System statu�: �Compllani ❑ Nonr,omplianl
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<br /> __....__..___ —_...,,_. (ps dptennined by this fortn)
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<br /> M��/d�a�rNic P�e�rFor�ar�ce a��d O�;her Go�pN�an�e� CompliancQ Inspection Form for Existi��c�SSTS ;
<br /> Compl�ance �ssue �`1 of 4 '
<br /> pe(e of obsenraGon: __3.- ��}�i���_.. .. Reason for observation: ,,,,'Q`�C?Q�'���.�C�„'�C_��_ _�
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<br /> This form expfres upon next insper.tion or in th�ee yEars,whichever occurs first: __.,,.�,_,,,_, �___ �—
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<br /> Gam�IR�I��Ge qu�estior��lcrifietia: (Require�) Veri#icatpon M�thod": (Opiional)
<br /> ____(Checic,tfie epprropriare box,�__,."„__. (Checl�l��e eppropriate box)
<br /> Does the system discharg�sewage to lhe []Yes l� Np � Searched for suriece outlet ►.(�
<br /> �round surface? --..:_._._..._......--- ,_...:...------
<br /> - ❑ Per#�rmed f�ydraulic kest
<br /> Does the system dischargr�sawage to drain ❑Yes �] No
<br /> tile or surFaco wa,ters?. ....__,__ � Seerched?or seeping in yard �ud ��y.�q or�,.i
<br /> Does the syslem cause sewag�backup '0 Y�s � No [� Ch�cked for backup in home
<br /> fnto dwelling,or o:tablishment? . .�,.,._,._ � Gxc�ssive ponding ln soll systemlD�boxes 1.10
<br /> Oo�ther aituetions bxist that have the �I Yos �Mo n Homeowner testlmony
<br /> potential to Immedlately and edversel�!
<br /> impAct or lhrea#cn public health or saiety ❑ C-�camined for surging in tank
<br /> ��lectrlcaf,unsafra covors,,etc.�? _,,,,,.;....___ � "f�lack�oiM"above snil dispersal system 1d0
<br /> qqy"y�es"a�nsw�2r Indicate,s tf�iat the sy'Pt�m Is an ir►amino�tt
<br /> tlsr�at to pub�k hea►th enoP sal'e�7V. _ ❑ Sysl'Qm requlr�os"emergerlcy"pumping
<br /> ----...�._.... ....... .. ...................._.._ .�__.------...._..._.._..T �] PetFormed dye test
<br /> boes the syst,em pose a threat to ground ❑Yes �No ❑ Other: �
<br /> water for�ny conditions deemed non-
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<br /> p�otectivo�r�detormin�d,by.the inspector7 � _ _., __....... �
<br /> „Yes"iru�i�ce[r�s that thQ system is f�ailing.!o,prv�te�ct ..._._.,,._,.___...-------_...,..:.�_i
<br /> g,round w�4x�r.If"yes", d�e�ar�be tFl�conditican noted: �
<br /> "No stande►rl protocol oxists. Th;s list is nof ex��eustiv�,
<br /> ,.,,.,. . ._..,,_.,_.._.___ rn sequontial oMer, nor does fi indlct�te which i
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<br /> r,ombinal�lons ere nec�ssa��to mal�e this dete►minafio��. I
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<br /> Ce�ti'FAca�ion �
<br /> This form is to be carnpleled and attached to the Summery Form oi lhe Minnesvta Pollutlon Conlrol Age�cy's(MPCA)Comn�liance !
<br /> InspeatBon Form far Exlsting 5ubsuPiace Sewaqo Treatment S�stems. Observations,interpro#ations,and conclusiona must be �
<br /> complet�d by an inspectar, Comp��ted form must be submitted to the loc�l unit of gduernment within 15 days, I
<br /> Proporty awner n�mo(s): _�� .��`. ...1.�-�---�Q_�r.t�l��-�- -•—,----- I
<br /> Property address: _a`�J_�____����'P�-�.1�1�'.�c�1_T_Q�,O..'l�.� _.._..,.,w__.,.�.— --_.., _. .---- .
<br /> P�oparty o�n�nQr's add�ess(If dlfferent): ,_,.,y,____ ________ ._ -. ._. ,
<br /> County; _L��'�L __ Properly awner phone_ � 'L� -� '--oj a,.0.,,�,_.. .—,...._—.
<br /> 1 h�rehy certify fhat I petsonally mede tfte observ�t�ons,ini�erpretel�ons, and concluslons reporfed on this foim and the((hcay�re
<br /> correct.
<br /> Name: `.��1°FhL�C�I�:•��`v`��1-��N14%;-:a�,�,., � CertifiCationnumber: ��.��............._.., ,--_ _..._..:...,__.
<br /> Businoss liccnsc narne�n�d number` 5 ' (� '1�'�i�;ri���. �� 11.1 L_� ^ �.�1 r��`�__;;.__�• � �v -z� "_►, �r'.',x r � oK
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<br /> Name of local unit of gover ment;
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<br /> Signatur�e: �� (/�r -�^-'r-..'_� ..._. DatQ: _���`a+R'R�—...,,:_�
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<br /> www.pca.state.mn.us • G51-296•6300 • 800-G57-3064 • TlY G51•282•5332 ar 800-657-3a64 • Availahle in altem�tive formaks :
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