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A,�9 p�y- 2015 05:29PM HP FaxRusty Olson 763498829� <br /> page 2 <br /> ta Pollution Com liance Inspection �orm <br /> � M+nneso p <br /> Control Agenty Existing Subsu�face Sewage Treatrr�ont g($STS) <br /> 524 Lafayette Road Nath <br /> 5c,paui,MN 55155-4194 <br /> Ooc Type:Comp►iance and Enloraemenf <br /> MP�A� � For loc � I <br /> ; � <br /> Ina#ructicng: �nsPe�'on resuks based on Minnesota Pollution Controalso ap y• � AUG 10 2015 � <br /> requirements and a���f�ocal Unit ofaGo ernment(LUG)and system owner I <br /> Submit comple4ed form t� � <br /> within 15 daYg <br /> System Status <br /> 7I1112014 <br /> System ataWs an date(mm(ddlyyyy)� liance <br /> Noncompliant- Notice of Noncamp <br /> liant-Certificabe of Compliance � rade Requirernents on pa9g 31 <br /> � COittp� See Upg <br /> (Valid for 3 yeers from report date, unless shorter time � <br /> frame outfined in Local Ordinance.) <br /> Reason(s)for noncompliance (check aU applicable) <br /> []�mpact on Public Health(Compliance ComP��t #7)—fmminent threat fo pubfic heafth and safety <br /> iance Component#3)—fmminent th+eat to public health and safety <br /> ❑Other Compliance Conditions(Co�r+pl� Failing to protect g►nu►►dwater <br /> ❑Tank Inlegrity(Compiiance Component #2)— Failing to protect groundwater <br /> ❑Other Compliance Conditions(Compliance Compo'nent#�3�rot�9roundwater <br /> ❑Soil Separation(ComP�iance C�+Ponent #4)— g Noncompliant <br /> �OPe�t��g permiUmonitoring p�an requirements(Compliance Component #5)— <br /> Parcel ID#a'SeclTN'P�Range: 2711823310026 ---- <br /> Property <br /> Information Reason for insped�an: Properlv Transier_ <br /> Property address: 2140 Sixth Ave. N,Orona MN pWners phone: <br /> Property owner: Paul Phillf a <br /> or RepreseMative phone: 612-719-4477 <br /> Owner's representative: Gre Larsen Regulatory authority phone: 952-249-4600 <br /> Local regulatory authority: Cit of Orono <br /> er city <br /> 2-1000 gallon septic tanks,1-1000 gallon lifl statwn and 500 square feet of mound radc �P <br /> Brief system desc�iption: records <br /> Comments or recommendati�s: <br /> Certification <br /> has been nor cen be made due to unknown conditions during system construction, <br /> 1 hereby certify that alJ the necessary ine�ation has been gathered to determine the compliance stafus of this sys em. <br /> determination of fufure sysfem per'fom'i <br /> possible abuse of the system,inadequafe maintenance, or future avater usag Ce��i��on number 1255 <br /> Inspedor name: Jose h J Olson License number: $�� <br /> gusi�ss name: Ru on's Soil&Perc.Testin <br /> phone number: 763-498-8779 <br /> InspeCtor signature: <br /> N��Sary or Locally Required Attachments �Forms per local ordinance <br /> �Soil boring logs �SysternlAs-built drawing <br /> �pther informauon(list): <br /> TTY 651•282-5332 or 800-657-3864 • Avatlable in altemative formats <br /> yyWw.p[a.state.mn.us • <br /> 651•296-6300 • 800-657•3864 • Page 1 of 3 <br /> wq-ww1st54•31 • 1/24/12 <br /> PaQe?of 3 <br />