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44 ,1'.- Pollution Compliance <br /> 4;w Control Agency Inspe� i®n Form <br /> 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems <br /> 'tit.Paul,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 (mm/dd/yyyy): - I --) <br /> Compliant-Certificate of Compliance ❑ Noncompliant-Notice of Noncompliance <br /> (Valid for 3 years from report date, unless shorter time <br /> (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 throat to public health and safety <br /> ❑ Other Compliance Conditions(Compliance Component#3)-Imminent threat to public health and safety <br /> ❑Tank Integrity(Compliance Component #2)-Falling 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 permit/monitoring plan requirements(Compliance Component #5)-Noncompliant <br /> Property Information <br /> Parcel ID#or Sec/Twp/Range: <br /> Property address: , :,<� ; <br /> Y °S` Reason for Inspection: stn, <br /> Property owner: 0 t-a�iS ��l Sc? \.-ti\. �° o— �t� Owners <br /> or phone: t -- r <br /> Owner's representative: <br /> Local regulatory authority: ,��, Representative phone: <br /> Brief system description: , - 'a G r.• Regulatory authority phone: <br /> Comments or recommendations: 0+,,^ti � �uv <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 futum water usage. <br /> Inspector name: <br /> Business name: ( Certification number (Q X12 <br /> Inspector signature: �(� , - License number. <br /> Phone number. <br /> Necessary or Locally Required Attachments <br /> a Soil boring logs ®System/As-built drawing ❑Forms per local ordinance <br /> 0 Other information (list): <br /> WWW,pCa.State.mn.us 651-296-6300 800-657-3864 c M 651-282.5332 or 800-657-3864 a Available in alternative <br /> wq-wwists4-.?1 0 1124112 ve formats <br />