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67128/2008 01:26 7634975011 A� SPTESTINGINC _—_ PAGE 02/05 <br /> � �V ^.. —__. ....__ .. _..._ <br /> i f � <br /> F���� r;�,, IViinnesota pollution �1r C '. . <br /> ��;;���;�,�`�,- ControlAc�ency '��P�����c� Insp�ect�or� F�rm <br /> 5z0 Lafaye�te Roed North E�pg'��n9 ;�ut�surtace S�evirage '�reattnent Sys�ems (3gTS) <br /> St.Paial,MN 55155-q19A <br /> Instructions on page 7 <br /> Parcel number; <br /> -�"--' ' , � For I�ocal Tracking Purposes: <br /> System stetus; ❑ Compllant � Noncompllant <br /> (based on ell complianca r�quirements) <br /> 5a�en�n�ry Fotrro <br /> property Informatior� � <br /> Property owner name(s): ����_ OU,��L„ , <br /> Properly address; ^��,,s �L�,��1•��� ,�U.� _, <br /> Property owners address(�f dlfPerent): w ' �- <br /> County: 1��„1�.���_ p�operty owner hona: - m g authorlly: �(��.p. ^ � <br /> p `Z����'�la.$►�r Per ittih �� <br /> D�te system constructed: ���� � � Reason for inapection: �'^—" <br /> Syste�m Descriptio� �� — <br /> Brief system descrlption: <br /> Local permit number: __ 7�u�� _ Number of bedroams: � '� ��� "— <br /> �_� Qoslgn flow rat�: (o�p <br /> Is tho systam: � —� <br /> In Shoreland a�ea? �Yes ❑ No in Wellhead protectlon Aree? <br /> An U.S. Environmental Protection ❑Yes. � No <br /> ngency(EPA) Class V In'ectlan Well? Yes SYstam serving�Mlnnosota depattment <br /> 1 ❑ [�Nv of Hea1h (MDH) licensed fecility? �] Yes � No <br /> COrnp(��nCe Std$L15 (Based on sta,te requlrements-additional local requir�ements may�Iso apply.) <br /> 6ased on tlie Information gathered and reported on altached fo�ms,the compUance siaiva of thie system is (check one}; <br /> ❑Certlfic�te of Compliance--valid untll (3 years fm►n date oFreportJ: <br /> �Notice of Noncompliance-For Noncompli�nt systems: -- <br /> 7he reason for non�ompliance is: <br /> This noncompliant system is classifled as (check ono below); � '— �-- <br /> ❑ Immfnent ihreat to publfc health&safeiy �Failing to protect grounc�wat�r [� Not fn compllance with opetatln � <br /> g pe�mit <br /> Cet'tl'F1CdtiOn (Complated form must be submitted to 1he Iocel�unit of government within 15 deys.) <br /> 1 hereby certify lhat all tho necessary infdrmalion hes boen gatherod to daterrrilne tho cornpliance status of this system. No <br /> determ�netia�of furure sysfem perfnrmonce has been nor r.an be made duo t�unl�nown conditions during system constn�ct;on, <br /> possihle abuse of tlie sys(�em, inadequate maintenancQ, or future wafer usage. <br /> Name; �,=�V����, ��.Q���_`� CertificAtlon number: __ (,�,�� <br /> Business license name and number: 5 -Q��c�j,�,� �G •►x,3�� nr_ " —��—• <br /> '_ � -' --,�-.A--�'�.�"'�4�-�.�'I�+(Q or <br /> Name of foca�nit of gove ment: _ ' <br /> Signature: �� '�a� ��� � ••�/ • <br /> � •,—�., _ Date' -.,� �.�'b <br /> Required Attachments Inspector Complete:This lnsp�ction R�port is pages long. <br /> ChecGt compliance forms attached: �HydrBulic P�rForm�nce ❑Tank Intogrlty I6�Soll Separaklon �Operating Pennit Fo�m(if <br /> appllcable) �Syslom drawing/As-bullt drawing Q�n ee9essment of any local requlremenls that are differonC from wh�t is requirod on Lhis <br /> form I�I Soll Boring Logs ❑Abahdonment form(ff epproprlete) ❑Other Informallon(Ilst): <br /> Upgrade Requirements(derlved fmm M/nn.Stat.§ f 15,65)�nlmminent fhrest fo pubflc lioa/th and�ePety(ItPHS)must be upgraded,repl�cod,or � <br /> !(s crse p/scanflnUeQ w/fh/n frn monUts d/recelpt of th/s notico orW/�1Nn a el)orferpe�lod/l requl�d py locn/olidinanCe.If the Ryatem!s lRf/(hg fo protecf ground <br /> wnfar,the syslem must 6e upgraded,ropleced,orlfs use dlsconf/nu�tl wl�h/n the Nmo requl�ed by/ocal ordlnance.!f an exfspn�system Is not ly0ing es tlellnedln <br /> lew,nnd Hes af lGestlwo feet oFdoslgn sq!l seperslloq,tnen Uio sysfem need no�ve upgraded,rope/red,replaced,o�I(s use dlscontinued,nofwl�Iistenelnp Ae�y <br /> /ocnl ordfn.nnce fhA(/s moie shict TIIlS provlslon does no!apply tp syafems ln ehore/end oroas,Wellheeq ProfeCUOn Alees,or rhose usedln eonnacfion wlfh food, <br /> beveroge,end Jodging ostabllshments as qeNned in law. <br /> wq-wwists4•31 <br /> 4/91nA Co171A1�fclnce Insnar.tinn Fnrm fnr Fvler�.,.. ccrr <br />