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01/24/2008 01:30 7634975011 SPTESTINGINC PAGE 04/07
<br /> Property owners) 5A,,a®�1 �1 - Fire No./ parcet No.
<br /> stm' Cgr�nonern9!; (Please descr%be the systEem aolrlponenty dnd attach Jfte slceit*showing system/owtfon):
<br /> N- eg f ' ms'. ,
<br /> 11_k13t rnetliod yv i sed t®irvaake-'AAjX=Irta ens fur the comnllenGS-insnectlon?(f(ote:No standa{d protocol exists:
<br /> The rd1lcwing list is notehiarwtrve,orin sequential ordernor/iidfcates ivhlch combin#tlons'mayne ry to make a de4ormfiatlon)
<br /> • a '
<br /> watertight tanlc(R) Hydraulic Functioning Vertical Separation Vl nce
<br /> ❑ Probed tank bottom, ❑ Smirched for surface outlet 10 •Cdnducted soil borings
<br /> ❑ Observed low liquid level ❑' .Perfolmed hydraulic test Deptli td limiting layer.7�-ll..fl
<br /> ❑ C-vmined const. records 0 Searched ft-seeping In yard WQ Depth to system bottom cw Vze% "Wo
<br /> • Examined empty(pumped)tanic ❑ Checked fbr bark-up.in home o bmnmined records 90'4 3'q'
<br /> o Probed outside yank:.for"black sol]" it Excessive
<br /> ponding In soil system/D-boxes ❑I L'GU UmilIng Layer Ver(ficatlon
<br /> ❑ Pressure/vacuum check ❑ Homeowner testimony .• ❑ Other
<br /> ❑ 01:11er— ❑ bxamined for surging In tank
<br /> F.jW%V40n TM' •5'1%-%-1VA0 0 Vlaek•solj':above soil system )1d
<br /> ❑ Other _..
<br /> Stitus.of the s st euro
<br /> used an the compllance crll:rada,,the-system status Is. (dieck one.) ,❑failing'(to protect groundwater) ❑ an
<br /> imminent threat tp pirbilc Itdaltil pr safety(ITPHS),'d nori=compllant'(moriltatirig issue) M cbrhpllant'(none of the 3,
<br /> previous conditions). 'Therelfore,this•doautnent is a: M—CerUncete of Compliance CU'Notice of Noncompliance
<br /> Ms this s'ysteirn•a'ti'EPA elass'1f EI1"ecllaan�lVel�7 i, D yes ® nM. o
<br /> C�atific�tion. .. � . _-� •
<br /> I.hereby certify as a state of Minnesota Iltensed•Inspector and/or Designer I or Quaafled Employee Inspector and/or Quallped Employee
<br /> Designer I t6t I conducted an Inves#igadgn that accurately detetmWed tho compliance status or this syAw and that my recorded
<br /> observations are accurate as of this date. Mo datermination.of future hydfaulic performance has been nor can be made due to
<br /> unknown conditions during system cdnstmcllon,abuse of the system,InadegU2M m3lntenance,or future water usage.
<br /> Inspector's name(print) 1'Gi 45(All w� Z_ Phone_ e)(a?, -- °-t"1') — oa...�
<br /> Ucensc and/or Regi otlon Number Address 9�'1 �K1-'S�'��.7 eP� L-.14•.
<br /> Smployed by i- Address ell', .t,L.6k
<br /> Signature �' �-�.._._---^ Dale
<br /> �Ps�de Reauir®[uentr,Ys ,(derlVedfinmM/nnesolastafules�,lt5.55)
<br /> An 17PH5mustbe upgraded,replace vrlbruse dlscogt/nued lWln ten monthsofMZPJ,otof b5/s noffiv or w/thln'a shorterperloelf
<br /> requfredbylecal ordinance rifre*%'Wn falls to ptovldpszWdwtgroundrva*pmtectlan,lien the system raiustbe-upymdo,
<br /> replaced,orfir use d1=17ffn&MeWbla the pmts r&7U1>rd by Mfg or,the!oral ofdlnance, If an ed;Mgsystem/s not fallIng as defined/n
<br /> law,and has atleasttwo feetofdeslyn loll separa#lon.Hien the system need nothd upgrades;mpslled,/eplaced,or/ts use
<br /> dlsaontlnued notwlitisbna7ng anylota/am7nanae diatlsmore This does notapp/y 6 systems/n shornJand areas,We!/head
<br /> pratectlon areas, or.diose uis�+d In sionnerlon MM f=4 beverage,and lodging estab/lsl'iments�s defined tri law, t,
<br /> 5uaaes ed,,Attachmentj
<br /> "Site siceLth cddld-gisd In6lude:well,Wall setback tp 5yiMrn,,dwelling orother bulldings,,,tank s),reserved soil treatment area,
<br /> s7&t&ce wa(�r and•sofl'borl6g locations. Include as-bullt diawing If available. "
<br /> z) Soil boring logs,'slicwing each'horizbn,`YAdlate ttig'texture,color,rMoAmorphic fealures dQpth•tn bedrock,st riding water,and
<br /> wltetliq the material Is till.
<br /> 3) A IiSL•of any.and all requlrertm®nts of theJecal ordinance thaL;Ire 410kaMt frim the slate requirements referred to on this form.
<br /> '4) A homeowner survey of system performance,signed by the horneoWner as being factual.
<br /> 5) Monitoring data as approorlate. 71
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