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• • 'Mrlinesota Pollution Compliance Inspection Form <br /> Control Agency <br /> ExistingSubsurface Sewage <br /> 520 Lafayette Road North Treatment Systems <br /> Sr.Paul,MN 55155-4194 (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(mmldd/yyyy): <br /> [11 Compliant Compliant—Certificate of Compliance ❑ Noncompliant—Notice of Noncompliance <br /> (Valid for 3 years from report date, unless shorter time (See Upgrade Requirements on page 3) <br /> frame outlined in Local Ordinance.) <br /> ( .{r'C4,l(jt V <br /> Reason(s)for noncompliance(checkall 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 /> ❑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 Parcel ID#or Sec/Two/Range: 'tK-a' <br /> Property address: I. \..Y ti'A \ Y ) - C-.j a Reason for inspection: f c,g °4 .� <br /> Property owner: "a'u'-,aQ--t '' <br /> ��4 uJ Owner's phone: (,) <br /> or <br /> Owner's representative: ,((Ari \ii( +�-!E,, r Representative phone: -,.a a - S L•a cs <br /> Local regulatory authority: ,G,-(4 y Regulatory authority phone: q{a,- Ria -1-1q.000 <br /> Brief system description: a- i u 01.) / I Quo a,.‘ cru.,� c, �. -Nots <br /> Comments or recommendations: w\-tit,i x y s ,Z,,,�,3 ,, 6, \, ,mon, <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: 5-f 'AsA , ),. j LNyc-M ,,moo Certification number. (( f <br /> Business name: 5 -i'? vN,1,\A 11„1�,, - License number: 301,t .- <br /> Inspector signature: Phone number: •?to;z) '4 r) - Z 5 <br /> Necessary or Locally Required Attachments <br /> iU Soil boring logs System/As-built drawing 0 Forms per local ordinance <br /> 0 Other information(list): <br /> WWw.pcastate.mn.us 651.296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 0 Available in alternative formats <br /> wq-wwists4-31 • 1124112 <br />