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• C J" <br /> .� <br /> Minnesota Pollution Compliance Inspection Form <br /> Cantrol Agency � � �isting Subsurfacs Sewags Trsatmsnt Systems <br /> 520 Lafayette Road North ��TS� <br /> 5�Paul,MN 55755-4194 <br /> Doc Type:Compliance and EnforGement <br /> Instructions: Inspection results based on Minnesota Pollution Control Agency(MPCA) <br /> For local tracking purposes: <br /> requirements and attached forms–additional local requirements may also apply. <br /> Submit completed form to Local Unit of Govemment(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 (See Upgrade Requirements on page 3) <br /> frame outlined in Local Orrlinance.) <br /> Reason(s)for noncompliance(check all applicab/e) <br /> ❑ Impact on Public Health (Compliance Componenf #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 Componenf #2)–Failing to protecf groundwafer <br /> ❑Other Compliance Conditions(Compliance Component#3)–Failing to p►r�tect grr�undwater <br /> ❑Soil Separation(Compliance Component #4)–Failing to protect groundwafer <br /> ❑Operating permiUmonitoring plan requirements(Compliance Component #5)–Noncompliant <br /> Property Information Parcel ID#or Sec/Twp/Range: <br /> Property address: Reason for inspection: <br /> Property owner: Owner's phone: <br /> or <br /> Owner's representative: Representative phone: <br /> Local regulatory authority: Regulatory authority phone: <br /> Brief system description: <br /> Comments or recommendations: <br /> Certification <br /> 1 hereby certify that all the necessary infom►ation 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 condifions during system construcfion, <br /> possible abuse of the system, inadequate maintenance, or futur�water usage. <br /> Inspector name: Certification number: <br /> Business name: License number. <br /> Inspector signature: Phone number: fi <br /> Necessary or Localty Required Attachments <br /> ❑Soil boring logs ❑System/As-built drawing ❑Forms per local ordinance <br /> ❑ Other information(list): — <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800•657-3864 • Avaitable in altemative formats <br /> wq-wwists4-31 • 1/24i 12 Page 1 of 3 <br />