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� <br /> � <br /> �� . <br /> � Mi�nesota Po��ution ` `'r� Compliance Inspection Form <br /> Control Agency <br /> 520 Latayette Road North ��sting Subsurface Sewage Treatment Systems (SSTS) <br /> S�Paul,MN 55155-4194 Doc Tjpe:Cqmplienc;e snd Enloroemen! <br /> _ . _. _....____ _ ._ __ <br /> InspeCtion roSu1t8 based on Minnesota Pollutbn Control Age►�cy(MPCA) For local tradcing purposes: <br /> requirements and attached forms-additional locai requinements mey also appiy. <br /> Submit completed fortn to Local Unit of Government(LUG)a�d syaeem owner <br /> within 15 days ' <br /> $�/StEfit $tatUS <br /> System sta�s on dabe(mm/dd/yyyy): 10117l2016 _ <br /> ❑ Compiiant—Ce�tificate of Compliance � Noncompiiant— Notice of Noncompliance <br /> (Valid for 3 years fiom repoR date,uMess shorfer dme (See Upgrade Requirements on pege 3.) <br /> frame oudined in Loca/ONinance.) <br /> Reason(s)far noncompliance(check all appticabie) <br /> ❑Impad on Public Heatth(Compliance Component�1)-Imminent fhr�al to public health and safety <br /> ❑Other Compliance Conditions(Compliance Companent#3)-Imminent threat to publ�c hea/th and safety <br /> �Tank Integrity(Comp6ance Component�2)-Failing to protect gr�undwater <br /> ❑Other Complianoe Conditions(Compiiance Componer►t�.?)-Faiting to protect gioundwater <br /> ❑Sal Separation(Canp/iance Component#4)-Failing to profect groundwater <br /> ❑Operating permit/monitoring plan requiremenis(Complianc.e Component!.5)-Nor►cbmpliant <br /> Property Information Parcel ID#or SeclTwp/Range: _04-117-23-43-0015 .____ _ <br /> - - <br /> Property address: 2730 Rainey Rd•Orono,MN _ Reason for inspection: Property_Transfer <br /> _ __ _ __ _ <br /> Property aNmer. Poterttial Bu�Rich Dellinger __ Owne�s phone: 608-332-7050 <br /> _ _ _ _ _ __ ___ _ _ _ __._ . <br /> or <br /> OMmer's represeniaiive: ____ _. __. _ _ -- -- Representative phone: <br /> Local r�egulatay auNiority: City oi Orono Regutatay authority phorre: 952-249-4625 _ <br /> _ _ __. <br /> Brief system desaription: 2-1000�allon tanks and a t000gallon pum�tank to a pressure fed_mound <br /> . _ _ _ _ _ ___ _--- ..--- <br /> CommeMs or recommendatians: <br /> Certification <br /> f heieby cefify diat ell the rrecessary information has been gatheied lo detemiu►e the oompliance status o/this system. Mo <br /> detemdnation of futu�e system perfom►ance has been nor can be made due b unknown corrditions during system carr�on, <br /> possiWe abuse ol tt►e system, inadequate maintenance, or future water usage. <br /> Inspector name: Tristan Ende _ Certification number. C9206 <br /> _ _-- _ __ .___ __-- _____. <br /> Business name: Ende tic Servioe License number. L2654 <br /> _ - ----1.. . .._____-�--- __._________.._. __. ._...__.______._.__. _---.____.. <br /> t►►spec;lorsignature: ''�.�_ Phone number. 763-428-4489 <br /> Necessary or Lxally Required Attachmenis <br /> �Soil boring logs �System/As-built drawing ❑ Forms per local ordinance <br /> ❑Other i�orrnation(list): <br /> -- -- — — -�_—._. _____ _ - _ _ --- - _ _ _ -- - - - <br /> www.pca.state.mn.us • 651-296-6300 • 80a-657-36M • TTY 651-282-5332 or 800-657-3864 • Avaitabte in altemative famats <br /> wq•wwists�f-3fb • b/4/14 Page 1 of 3 <br />