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nesota Pollution <br /> 1::Lx Compliance Inspection Form <br /> Control Agency <br /> • <br /> 520 Lafayette Road North Wsting Subsurface Sewage Treatment Systems <br /> St.Poi,MN 55155-4194 <br /> (SSTS) <br /> Doc Type:Compliance and Enforcement <br /> Instructions: Inspection results based on Minnesota Pollution Control Agency(MPGA) 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): <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 /> ,3Yu,4 i •• fil,• <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 /> ❑Tank Integrity(Compliance Component #2)-Failing 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: <br /> Secrrw /Ra�e: <br /> C 0.Pro a address: )�o <br /> ) Reason for inspection:owner: <br /> or Owner's phone: a <br /> Owner's representative: <br /> Local regulatory authority: C, -(4 o! Representative phone: <br /> Regulatory authority phone: S <br /> Brief system description: }"wJ ,..-0 <br /> Comments or recommendations: -Qt h -� � �� jti s Y c c�qct� r.� 5 1 <br /> 5.Sl V-4 }-0‹, 4- WI <br /> Certification <br /> 1 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 • 6. Certification number. <br /> Business name: 5 ---c) <br /> .( �.('t��` <br /> .- 11_1 C � License number: <br /> Inspector signature: , <br /> Phone number: ✓)en ne <br /> Necessary or Locally Required Attachments <br /> ® Soil boring logs M 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 o M1651-282-5332 or 800-657.3864 0 Available in alternative formats <br /> wq-wwlsts4-31 1/24/12 <br />