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Nov. 6. 2 12 12;47PM No, 1056 P. 3 <br /> .� . r� , <br /> • ;��.�� i�nesota Pallution • <br /> .��r����� Com l�a�nce Inspection Form <br /> ��"R �_�� ontrol Agenty p <br /> ..�,,:;�v <br /> 5 �la[ayette qoad North Existing Sybsurface gaw�9a �tm�nt Systems <br /> 5 P7ul,MN 55155-4194 <br /> (SSTS) <br /> Doc Ti7�:Canp�piarxx end Enlw�rnent <br /> �nstructlone inspeciion results besed on Minnesota Polfufio�Confrol Agerxy(Mp�q� For local tr�cking purposes: <br /> requiremer�ts nd attacl�ed fortns-additional Ioca1 requiremer�s rney also app�y. <br /> Submlt com leted fvrm to 1.pca�Unft of Govemment(LUG)and sysbam owne� <br /> withln 15 da <br /> System S tus <br /> System status on date(mm/dd/yyyY1� �t��1 r�Z <br /> ❑ Co pliant-Certiflca�of Compliance � Noncompliant-Notice of Noncompliance <br /> (Ve for s y�ears/rom r�pp�ds�. unless shorte��irr�e (Ses Upgraa►e <br /> ,- !ra oubined Jn t.ocal Ordinance.) �Wuliemen�s on pag�9� <br /> Resso (s)for noncompliance(check ell appliceb/e) <br /> ❑I act on Public Health(Compliance Covnponent #1)-Imminent thn9at M public health and safety <br /> ❑ er Compllance Condfions(Compliance Canponent�q)��mm;,►ent throat ro public hea/th and sef�ly <br /> ❑T k Integrity(Comp�ience Compo��t #2)-Feiling to prol�ct g�undN,ater <br /> ❑O er Compliance Conditlons(Complianc�e Compo��M�J-Fei�nq do proi�t g�n�,yafer <br /> � I Separation(Complianoe Camponent #4)-FeQing�p p��groundwater <br /> Ca 0 ►�8n9�rmit/monitoring plar�requlremeMs(Comp//8nco Component #5)-IVorrcomppant <br /> Property I formation. <br /> Pa�cel ID#or SecJTwp/Range: <br /> Property addre : _ a 0�S O 5�-1 v .�[,�►�1�r,Ri o� in Resson for ins ection: <br /> p�m,� •—,—Q..,�,� p � <br /> or ONmers phone: <br /> Owners�ep ntetive: ���.. 'rl�•l7 M�-S Represent�alive phone: (�S -'�17�9! <br /> Locai reguleto authorlly: � Regularory authoriLy phon�: o � <br /> B�fef system d crlption: a S / � q�,� . �,,��. _ L� - , a <br /> �a t, , ('(0 u p�.�� -�0 <br /> Comments or mme►tdetions: �(�y ��F v"t,�9�-�Q 'i��'Sr11L ?�p r.l.� F1,C71.0 LI1.1�� (oDW'�v�°`-V-� n�g'�� <br /> Certificatio <br /> 1 heroby certily at ell the ne�essary in/amaGw►hes been 8rather�l�o�te,mine�e�npllance s�eh�s of this system,� <br /> determlr►alion o ture sysl�em perfoimence has been nor can be made due b un/a►own condltlons dum�9 sY�cons�iucbion, <br /> possible abuse fhe system,inadeque�e melntenarrce,prfu�p�i�v�(�r�ege � <br /> Inspecbo�name; ��i y(� � ,/� �L ��,_ Cem�ca�n number: <br /> eusiness name� 5 -� .(' --�.a� <br /> , Licenae number� ^- <br /> Inspector signa ; ��. �i).f '.,;,� ,c"_�,_,_� � Phone number: �j .� <br /> • --._. <br /> Necessary o locally Required Attachments <br /> �Soil boring I gs �.SysterrVAs.bui7t drawing ❑Fprms per tor,�l ordinance <br /> ❑Other iMo ffon pist): <br /> �.DW.St�te.mn �c . r.c�_�oc c��,�. ...... .----• <br />