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IU:dWow, <br />T-420 F-DOZA03 F-T48 <br />MAY-9-200, Ze.16 FROM:MERWIN 8 RSSOCIATES 7638560901 <br />NAY-04-2008 14:12 FRMFCALL CENTER r , <br />- • Property <br />5)11,tem components (Please descrf6e the <br />Fire No./ PArcel No. <br />and attach s/te sketch shora/ng 5wep" /orat/on). <br />What Methads wgre used to make the datermInAtlons to the comalla Eg lnsoeRton7 (Note: NO sARda(d prolDCCl eXt <br />The faal tV lar Is not eMausObe, Or In SWUMdrl ordereor,nmcares wa,vr 1PMb4. . m , necessary ry make a ewemrlwe <br />WateMght tank($) <br />y11—Probed tank bottom <br />t%/t)bsarvad lore Ilquid level <br />q emmined consL records <br />a emmined empr/ (Pumped) tank <br />a Probed outside tank for"bladt soft" <br />a-praavre/vakuum-check <br />a other <br />Statusof the system _ <br />Hydraulic Functioning <br />Searched for Curfap Outlet <br />o performed hydraulktest <br />P"Searthed for seeping In yard <br />p Chedeed for back-up In home <br />O ESrcerstve pondin4 in Sol! system/t)-tioxrs <br />0"'Homeownar tes"orly <br />O Examined for surging in tank <br />O "Black sot, above soil system <br />Cl Other <br />1 QttLcal Separation Distance <br />Conducted soli bonny$ _ <br />Depth to limiting fayer <br />Depth to system bottom <br />a Ermined records <br />o •LGU Un11Cn9•Layerveriflca7on• <br />o . Other - <br />" tole one) Q failing (to r groundwater) O an <br />Based an the compliance criterlar the system s1to is; <br />imminent threat tu-public health or safety (r PHS), 0 i>on Pliant (monitoring issue) compliant (nacre of the 3 <br />previous conditions), Therefore, this:docurnent is a: rtificlite of Compliance C3 Notice of Noncompliance <br />Is this system an EPA Class v Injection Well? 0 yes 0 no <br />t hare ration r and/or ceigner I or Qualified Employee Inspector and/or Qualied EmplOr <br />i hereby cetCry as a sots of Minnesota Ileensed inspector d/ and that m recorded <br />Designer i that I conducted an Invest7gation that accurately def NtU ed the comPOf" embus Mance a this system nor can be Y <br />unkn�wvrrnocondltions during rate system oof this ate. No detenYdnatla <br />nstruaron,nnabuse of the sYmm, In decluatee malnnteriancee or future re water usage. a due to <br />Inspector's name (print) VA,, re' � %}• (`��� Phan•, & 3 — ? 77� 7 C l - FF0 <br />ueense and/or is dori Number Address. PO l3 'at 3 <br />=ZS 9A'&ess r� 110 rY1 H S.S3 �. <br />1 Date t/-11�� <br />Srgnatvre � . <br />�[poiadB.Aeauirrr�ents rotmrhedramMaart�tivs@tuteslflS.S3J <br />An PMmW be upgraded, err la use dl&-m r& ed w4ft tent mon4hr Ofrecerpt of MIS nobler or rrlth/n a shorterpenrod �` <br />reiquri+eo brlocal ardpaarlce If drs sysresm fads to provide suAFdeotg�mdwaltYprrztecoaL the'r the s)nye�++ mustba upg�adaQ, <br />rVleced, orb use o2a10 ft ed *Y00 brie rime nsqukr+d byrvk or the local ora7P+ant+e> If an /t4 system to rrOt as arnllhec:/rr <br />law,. 400ar dw dre system need nor 6e wgr=w, repiffda4 to pkcact orbs use <br />dlsandnued, m�9 anyPoral ardlnancr arat&mart: srikt 77fds ObeJ not apply lb systa�nr In slfoteland anta� wellhead <br />usedllt connaerdw► w/Ur fob devera9G and kdg/nQ extbbfishments as dr1lnad hr law. <br />&uaaest d Attachments <br />i} Sitp ipgool cquid.alao lndude: web, well setback Oo system, dwetling or outer buildings, lank(;),reserved loll treaanent area, <br />surface "atarand soll•bcWng•loeaeans: include as-bulR drawing It aw1100ie. <br />2} ° scn banny-togs Yhowtng each horizon. Instate the texture, color, redwdmorphic features debth to 4eerod4 stance = water and <br />whether the material <br />Is . <br />3) A Astof any and all requirements of the local ordinance that are ci ferent from the state riiqulrements referred to on ifs form. <br />9) A homeowrfer survey of system performance, signed by thkt=cQWner as being factLm" Y • . <br />SJ Mopitortng daft as appropriate. <br />Pa§e 2 of'2 <br />