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1 U: Gbaa i .~ . <br />~ T-420 P.OOi/003 F-749 <br />MaYN~1Y 04~-26008 0 6:12 FRfIL CENTER SSOCIRTES 7638S609ei <br />~'Yl_._,.~~. /'~~ __ _ _ Fire No./ P reel Nv. _ - <br />- - • PKOperty Ownef(s),,,..t .!~+,~ ~ _ .nom w _ ./ ~ /i~• ~/i i,wr-. <br />~~tem Gom onenGs (Please destt/be 9're sys~~pa~nenGS end attach ~~ sketch show/n9 ~~+~~/~ <br />~r-,~ _ r .-i.._ !~~ <br />u1FS~ rnernnna y`@rg USed !o Ma1kE ~' '~ ~e l~..rl~ns for the comnIlance insneo*_'tonT (Note: NC sCdli~~ <br />rna loppwing lulls rmt eXhaas+7Ve, Gt In se0uandal pldelnorinaYcaras wh~dt cwnb/naCOnr maynK>9:rSdry lt7 make a detdm/naCc <br />W~tartl9ht fink(s) <br />~""Probad tank bottom <br />r~~Otuarved lOrr nquld laud <br />q [yramined consC. nxords <br />p Examined empr/ (PumpEd) tank <br />Q Robed oucstdg tank for"~adC soA- <br />a -t~sdry+wcuum-Check <br />G Outer <br />tiydraulla Runc!(ontng <br />t6~Searched for surtata Outset <br />d PerfOnnYd hydraulkteR <br />Searched for Kcping In Yard <br />^ Checked for bade up to home <br />O Exces~ve Pig ~ sot! systemlD-twxes <br />meotvnar testimony <br />O F~tamtned for staging to tank <br />p "Blade son' a0ove soli system <br />q Outer <br />llettJcai Separatlort Distance <br />Cpnduete0 loll bOnngs ~ ~~Jryyy~~~ <br />Depth tC Ilmitlny layer. ~ p it <br />Depth to system bottom <br />q ~rrrirted records <br />o •Wtl umitlrtg•tayer VeriBcatfon• , <br />o . ether - <br />lotus <br />'' •" • - ecic ofle) Q felting (uo prgieEr groundwater) O an <br />8asetl on the eomp.Qance rriterla, ttte_system status ist i-ant manitortn Issue) ~omptiant (none of the ~ <br />Imminent tllteat tti'pubilc health or safety (riPHS), O non ( 9 <br />previous carlditlons). TTseretore, this:docutnent is a: rtificate of Gampliance D Notice of Noncomp!!anee <br />Is this systt:m an EPA Glass V Injecl:ion Weii4 O ~ ~ <br />~ertiRcatlon <br />I heretry cettlty as a state or Minnesota llcettsed Inspector and/or pPStgner I or Quan~fed Employee inspector and/or QuaIItled t3nploy~ <br />Designer i tltat I conducted an InvsstigaHon that accuratey detamtned me Comp9artce Scotus Of this system and That my ratonded <br />observations are acwrate as of this 6a ~~N c mat se of ate system, !^~adroMuat~ nor ancsa orr tt,ture water ~ ° due to <br />unknovm tandlCons dtNlnQ system (~ <br />Inspector's name (pearl ~A h ~'G ~ ~}• i `e.~~ ~ Phon (3 - ~' 0 ~ ~ ~9p <br />Ilceltse and/or tl'on_~N_umber ~ ~! ~Ke_'~~A,ddtess yh~~~tp~~0 ~y/3' a 3 <br />t'.mptoyed by ~~s W 4 b... <• 9pppraSS "~ n ! FG a /~o /~ h ~~~ ~ .~ <br />~ ~~~, ill y-~ <br />Ssgnaturc -'~ ~• <br />-,~(gcrade.Reau_tre!ments rdmrvedltwnMb~n~sren~s3lIS.S3J <br />•Rn l7PN8muat ba Opgrsdait~ ai/a use atsuad wRYh6i tent rnon4'rs ofrees/pr o,,/d7ls nodcr of wldr/n a ShOltt/Pe/1ad h' <br />repakeo6rloeiar oroaaance /lrhe sysnsm faAls m proNda saAfdenrg~ndwaterArnteroty~ th~rr the s}~stenr mustbe upgraded <br />ieplaced. orRr use dluanOhruGd w/Cdn Ohe Gme m~rkrd byrv/e ardre loca/orWi+anc+a If an system ~ notlkt+bapas a-~+e~'y+ <br />/aw,.ans/.MeaSk+isrA-±o•+ie~raratar~n•ao!/s~gataraabrti obdr Dhesysmvrtneednot6e t~graOrC~r1, iepn/~G(, /ep~ w'~use <br />dlsarrdnued m~9'rny/oC~! ora9'nanGe' teat LsmotssOkt 7Trls apes natappv/ym systavcs /n shor land arm wee/~aed <br />P!R(I and; gtCjare asrd/n ciorrnt+ctlon wRh /o~ad, L,ttwrayey and k~cl9ay etstrhAislunents as o'rllnad 1~ /ast: <br />Suaae.~ed ,Attachments g ed soil b+eaane+ft area, <br />;} S.It6,ip4gth coyJd.also lndude: wen, wen setbacit to system, dwelOng or otlter bulidin s, tank(;),resew <br />• SUffate ira[erand sali•ttodng•locatlons. Irtdude asdwtk OrewtnB !r awdsbie. <br />z) ° stn bonng•toga; showing each horizon. Inelcace the texture, Color, redo:dmorPhtc features depth co t~edrock standfa9 water and <br />whetlur dla material to Rtl. <br />3) A nstof any and a0 requirements of the Local orginance that are dtftetenc from the slate ~quirements referred to on~tis (orm. <br />9} A homeawrler survey of system performance. signed by tha,~sameorrrier as bein~facnat. h - • . <br />S) Mnpltoring data as appropliaae. - ~,;r. , <br />• Page 2 of'2 <br />