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I U: em..=,..,, <br />MAY-9-2906 08.16 FRF ILICENIER SSOCIATES 7638560901 <br />* T-420 P.002/003 F-7d9 <br />W1Y-04-2008 14:12 <br />Prwoperty owner(s) _ L Fife �Io./efcel Ng. <br />r��tem Comgonen ea (Please describe eye intern fvnrparen& and atwae site skeerh shoWng system /oration): <br />what Methodse used tam ke the determin-Atlon or the comnllanca Insoecttonj (Kate: Kosta VWPA7x=exl <br />17se (oA mk_q list iS not evhauSAWe, Or in SWWO'el adernorindkares wh,dr teach/moons mey necessary to make a detNm/Radc <br />wa.tartight tank(s) <br />J111—Probad tank bottom <br />r�/Dbsorved low tlquld level <br />cl Wmined onst records <br />O Examined empty (pumped) tank <br />a probed outside tank for•"biadC SW <br />o-presshe/racuum-check <br />O titer <br />Hydnulld Functioning <br />qk,lo-Saamhed for cwfM outlet <br />o penbnnad hydraalktest <br />Searched for seeping In Yard <br />p Checked for back-up in home <br />p eve ponog, In $olo sysWn/o-taxes <br />0-**H-0meormar testimony <br />a Eamined for surging in tank <br />p "Black sail" above loll system <br />a other <br />r"Yet#ltaI Separation Distance <br />COnduexd soll bongs _ ,- <br />Depth tC limiting layer <br />Depth to system bottom <br />a 0olmined records <br />a -WU umitiVt.tiyer verification, <br />o . Other <br />tut e <br />Sasetl on the compliance rrlterla, ttte System status HP <br />ecK e) ❑ falling (ba j�""Ilaroundwatpr) an <br />imminent threat td-pubi(c health or safety TPHS), 0 nonnt (monitoringis Issue) iN tune t (cane is the <br />previous conditions), Therefore, t hisidocument IS a: dte of Compliance ❑ Netice of Noncompliance <br />Is this system an EPA elate V Injection Well? 0 yes 0 no <br />tertlfiratlon <br />I hereby artily as a state Of Minnesota licensed Inspector and/or oesigner I or Qualified Employee Inspector and/or t)u-rnfled Employ <br />Designer I that I conducted an Invastlyadon that accurately determined the compUance SMWS of tills system and that my recorded <br />observations are accurate as of this date. No determination of future bro aauwtP� !na ternce has <br />or future re water usage. nor can be a due to <br />unknorm condrtfons during system Conlstruetlon, abuse of the system, <br />Inspector's name (pnnt)�� n rG r � <br />license and/or �1s�b1ja.�non�-N"umber st. PO !3 a 3 -- <br />Employea by L�c.p+tiS wG ��••-• i �A'�dress 1Y10 .,TFe e. !%,� /'t/1 ti S`S� G �// <br />Date <br />signaNlre _ <br />�Jpgrade.Aegvlrer�tenb rderroedrianMmneNew mnnesf!lem <br />•Rn liPli.£moft ba upgradauG re�dac� oy � use d/ssnrrb)►ued tnm'tA! rent rnon4'kr alrecslpt Or Oft noUcr of wrlYryr a thwtd'perldd /)` <br />regljkw by bovtAhanCm !/the OMNM fads m pjoWaa suAroknrgnwndmA rprote bbft, Chem lire rystem must ba upgradecL <br />rat <br />nrFvaced, or& use d.1;=0'nued width dye One re U#ed byrvk ar file kcal adNranm If an cdWitgsystem h mui�a!lbryas d On4d or <br />law,. and(asra(hWA+o-,tr -arbM7Mesymarrneednoebe4wridetd, repx#ec� feplaet4 aria use <br />dL4earbirrreo, cry low/ an#nanM mac trMM sbfct: 77sis abet not apply tb sys7&ts fn shOMdand arr,L7$ waO wd <br />P!Rftob?mn•4`bi N mo,In cvnnsrbron tv/dr roe bswfragR arrd kefyViy arablishmen[s as drlinad 1n low, <br />Suggested Attachments <br />1) S.It -04;o:n cartd.k(w Indude: wen, well setback to system, duelling or other bulldingsp tank(;),reserved son treatment area, <br />• sulfate rraterand soll-borfnq'focagons. :nCude uilt drawtnB If avallabre. <br />2) ° Scll bonny loge, showing each horizon. Indicate theas-bto ture, color, redoadmorphic features depth to bedrod4 standing water and <br />whether (he material is mi. ~_ <br />3) A Ilstof any and an requirements of the iocal ordinance that are different from the state !Iulrements referred to on Mls form. <br />9) A homeowner survey of system performance, sighed by thCi_+omeowner as !xlifaeetat. - . <br />S) Mooltoring data as appropriate. - <br />Page 2 of"2 <br />