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�;� . Minnesota Pollution �ompliance Inspection Form <br /> Control Agency <br /> 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems (SSTS) <br /> SC Paul,MN 55155-4194 Doc Type Complrence and Enlarr,emenl <br /> I�speCtiOn resuits based on Minnesota Pollution Control Agency(MPCA) For local tracking purposes: <br /> �equirements and attached forms-additional local requirements may also apply. <br /> Submft completed form to Local Unit of Government(LUGJ and system owner <br /> withi� 15 days <br /> System Status <br /> System status on date(mmlddtyyyy): 10/17/2016 <br /> ❑ Compliant- Certificate of Compliance � Noncompliant- Notice of Noncompliance <br /> (Valid for 3 years/rom repoR date. unless shorier bme (See Upgrade Requirements on page 3.) <br /> /rame outlined rn Local Orrlinance) <br /> Reason(s)for noncompliance (check all applicabte) <br /> ❑ Impad on Public Health(Compliance Component#1)-fmminent threat to public heafth and sa/ety <br /> ❑Other Comptiance Conditions(Compfiance Component#3)-lmminent threat to public health and safety <br /> �Tank Integrity(Compliance Component#2)-Failing to protect groundwater <br /> ❑Other Compliance Conditions(Compliance Component#3)-Failing to protect groundwater <br /> ❑ Soil Separation(Compliance Component#4)-Failing to protect groundwater <br /> ❑ Operating permiUmonitoring plan requirements(Compliance Component ll5)-Noncompliant <br /> Property Information Parcel ID#or SecJTwp/Range: 04-117-23-43-0015 <br /> Property address: 2730 Rainey Rd. Orono, MN Reason for inspedion: Property Transfer <br /> Property owner: Potential Buyer. Rich Dellinger Owners phone: 608-332-7050 <br /> or <br /> Owner's representative: Representative phone: <br /> Loca!�egulatory authority: City of Orono Regulatory authaity phone: 952-249-4625 <br /> Bnef system description: 2-1000 gallon tanks and a 1000 gallon pump tank to a pressure fed mound <br /> Commenis or recommendations: <br /> Certification <br /> 1 hereby ce�tily that all the necessary infomta6on has been gathered to defermine the compliance status ot this system. No <br /> determination of futuie system perfonnance has been nor can be made due to unknown conditions during system constructron, <br /> possible abuse oi the system, inadequate maintenance, or Iuture water usage. <br /> Inspector name: Tnstan Ende Certification number. C9206 <br /> Business name: Ende tic Service License number: L2654 <br /> Inspector signalure: �.`_ Phone number 763-428�489 <br /> Necessary or Locally Required Attachments <br /> � Soil bonng►ogs � System/As-built drawing ❑ Forms per local ordinance <br /> ❑Other iriformation(list). <br /> www.pcastate.mn.us • 651-2%-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657•3864 • Available in altemative formats <br /> wq•wwiscsa-316 • b��l ra Poge 1 oJ 3 <br />