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zx.r <br /> br <br /> r rt tvttinesota Pollution <br /> Compliance Inspection Form <br /> ontrol Agency <br /> Extstin <br /> 520 Lafayette Road North g SubsurfaceSewage Treatment Systems <br /> 5L P4ul,MN 55155-4194 <br /> (SSTS) <br /> Doc Type:Compliance and Enforcement <br /> Instructions: Inspection results based on Minnesota Pollution Control Agency(MPCA) For local tracking purposes; <br /> requirements and attached forms-additional local requirements may also apply. <br /> Submit completed form to Local Unit of Government(LUG)and system owner <br /> within 15 days <br /> System Status <br /> System status on date(mmlddlyyyy): ; --T.3_N`r! <br /> [❑ Compliant-Certificate of Compliance ❑ Noncompliant-Notice of Noncompliance <br /> (Valid fora years from report date,unless shorter time (See Upgrade Requirements on page 3) <br /> frame outlined in Local Ordinance.) <br /> Reason(s)for noncompliance(check all applicable) <br /> ❑ Impact on Public Health(Compliance Component #1)-imminent threat to public health and safety <br /> ❑ Other Compliance Conditions(Compliance Component#3)-Imminent threat to public health and safety <br /> Q Tank Integrity(Compliance Component #2)-Failing to protect groundwater <br /> ❑Other Compliance Conditions(Compliance Component#3)-Falling to protect groundwater <br /> ❑Soil Separation(Compliance Component #4)-Failing to protect groundwater <br /> ❑Operating permit/monitoring plan requirements(Compliance Component #5)-Noncompliant <br /> Property Information Parcel 111#or Sec/Twp/Range: <br /> Property address: 0 ',,� ark . <br /> � P , <br /> Reason for inspection:-c- -o\-905.--(1 <br /> Property owner: - � g <br /> or Owner=s phone: 41 '7 - 4 -iL <br /> Owner's representative: Representative phone: <br /> Local regulatory authority: o4?-1.9 • Regulatory authority phone: ,�,7'a-4 9-y,,00 o <br /> Brief system description: to so 41000 41 6 ;jC Y�a � 13\rac9 f%",,1ua 464-0,4 0. <br /> Comments or recommendations: +.01 )-1 ►�} ro',t r741 120r.Y-1:1°-, y rte, v , C, �-) `- <br /> Certification <br /> i hereby certify that all the necessary information has been gathered to determine the compliance status of this system. No <br /> determination of future system performance has been nor can be made due to unknown conditions during system construction, <br /> possible abuse of the system,Inadequate maintenance,or future water usage. <br /> Inspector name: {�y Y�� .�L Certification number. <br /> Business name: 11' . 'mat 1.� � <br /> )��I License number. <br /> Inspector signature: • , -- Phone number: qco --49.1) - <br /> Necessary or Locally Required Attachments <br /> Soil boring logs ei System/As-built drawing 0 Forms per local ordinance <br /> 0 Other information(list): <br /> vencpca.state,mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282.5332 or 800-657.3864 • Available in alternative formats <br /> wq-wwists4-31 • 1/24/12 <br />