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Nov 06 13 06:50p 763-213-0695 p.3 <br /> �. Soi! Separation—Compi�ance component�f4 of 5 <br /> Oate of in�llation: _��� ❑U� YeNfication me�od(s�; ' <br /> �o���0��� �Yes ❑Na Sa7 a�s�rv�tion does not exp�+e.Pre�ious sorl <br /> obse�vatf+oRs Dy two indepenrle»t pa►ties are sr�f'rclerat, <br /> Co nce crii�ia: rmless srTe c arraGt;ons have be�en aA�ere�av�Aoca! <br /> Forsystexns b�r p�Orto,qpM 1, rsgs.arld ❑Yes ❑nro ��,�ts dr�ar. <br /> ►1ot locafied in.ShorHanol or N�INread � Conducted saf observa�on(s)(A�arah borinq bgsl <br /> Proteclion Ar�e ornotsewing a t+ooc� ❑ Two pre�rious veri�ia�,a(AaFedr ba�ngMgsl <br /> beveiage orloafg�}�g��' ❑ Nd appricable[Hofa6ris iank(s�,rno�infielrll <br /> Drainfreld has at i�st a lwo-foot voertical Q Uhable b ve�ify(See�Cammentsi�zplanationl <br /> separatian dlstartca from periodicaBy <br /> s�rated soi or bedrock. ❑ Ofher(See � . <br /> Nae-Perfo�mance systems bre7t Apri11, (�Yes ❑No Commenls/L�xplana�on: <br /> 9996,orlaGerorfornnrr perfomtance <br /> systetns bcate�d ti�Sl�oreland or We�Vfread <br /> Pr�t+�cUori Areas orse�virg a f�d, <br /> ��a►'�+9 esfab�isl� <br /> Orainfield has a three-fioot+rertical <br /> se�ration distarw�from perio�iCapp <br /> saWr�ed sail or bedrr�ck.* <br /> ,FxAerimen[al:Olher; or perfio�»aenae' ❑Yes ❑No ItuGcabe de of elevatiw�s <br /> sys6ems bur7f underpre-20Q�8 Rule�Type 1V <br /> or V syster►►s b!/Rf W 1de�r 2U08 Rr�feS(7080. , R. Boqom of distrilx�tion rsiedia - I <br /> 2350 a'7080.24Q0 (Adv�noed tr�spe�ctor <br /> LiCense requiraae� & Periodica sahnated sa7fbedrodc / <br /> arair�ld mee�s the designed verticat . . . i <br /> separation distance from periadic�ly C' <br /> sahuatect soil o�bedrodc. D. uired • �j � <br /> �QDy"AO"8►ISyV6r'860Y@ jlfdlCB�BS�3y5El�fl/IS `May be reduoed up bo'!5 per�nt if�bwed by Lopl <br /> Failfng to Profect Groru�ahvater Ordir�,oe. <br /> 5. Operating PeTm�'it and Nitrogen BMP"—Comp��ance component�r,5 of 5 �Not app6cable <br /> i�.�� � � .... <br /> Is the system opera�ted under an Operatin9 permit? ❑Yes D No If•yes",A below is requlred <br /> Is the s�rstem required to employ a tVitrogen BMP? ❑Yes ❑No tf"yes".B belaw ie�equired <br /> BMP=&est Manegemant Pracaoe(s)spec�7reaf in the sysfem demign <br /> If fNe answe�r to bo�fi ques�iwis is"no;�hls section daes not need Oo be comple�ed <br /> Co�n liance c�teria - <br /> a. Operadng Permit n�anber: <br /> iiave the Pertnit uremer�s been met? ❑Yss ❑No <br /> b. Is the uired ' 8MP ie �c! funclipni . Yes No <br /> Any�no"answer�Lta�icates Nancompkanc� <br /> tlpg�ade Requlren�aMs(Minn.SteC§7i5 5u7 An bmrYr�erX tlxea!fi Public f+eallh and s�lialY(!7�°NS)rnust be qpgraded�or itc we <br /> �saav�'vwe�d wdhJfn l�n morMhs ofieaeipt of fhis na8ioe ar w�hin a sNorterpeiiod/frequ�►�sd bY loce!ord�.!f ihe aYsfem Is fsAlrlg to p�tect <br /> grau�d wa�ar,the sysd9m must 6s up�raded,�BP�Boed.ar r�use dtaaan�riued w�Hin d�s 6r►es�qrei►ed bY laceel a�aGnr�!f ar�exiadi�p system <br /> is�rot feAYnp 83 delFr�gd in/aN;andhas etle8st fw�D!(a�t Of design sa7 sepera�inn,d�an bhe syslam nsed rrot be r�yogradec�,r�qpsrred�plaoea�or <br /> �ts erse�ioontkx�q��Y�or+�nen�ae�/s mor�sb�Ct. 7Als pror�ilbn does not apply ro sqsle,m�s in.sAa+eJand meas <br /> WeO�raad Pra�n,4r�es,ar 8w�se Usad i�r�auiec6o»wvEh fooa�bererage.and Jodgfing�aa alefu7ed in faw. <br /> www.pa.state.mn.us • 651-296-63QD • 800-667-3864 � 77Y 651-282-5332 or 80d-b57-3864 • Ava�abbe in altemative formats <br /> wq-wwlsts4-3i . 1/Z4/12 <br /> Pbqe 3 of 3 <br /> ( <br /> 1 <br />