|
07/17/2698 64:23 7634975011 SPTESTINGINC PAGE 03/09
<br /> , '
<br /> ,,;:,:. ����. 'Minn�sota Pollution C rnpli�nc� Nnspection �F
<br /> ''��f� orm
<br /> • Control Agenty
<br /> ��.
<br /> . 5z0 Lafayecte Road North �xisting Subs rN,ace Sewage '�'re�tment Syste�nns (gSTS)
<br /> SL Paul,IUIN,5155•4794
<br /> lnstructions on paQe 7
<br /> Parce)number: � Fo�Local Tracking purposes:
<br /> System st�tus: �Comptiatrt ❑Noncompliatrt �`
<br /> (based on all compliance rt�qulrementsJ
<br /> Symmary �ornn
<br /> Property Information
<br /> Properly awner name(s): M �,,L g
<br /> Properly address: �4� C� ,�p�(
<br /> Property owner's�ddress(if dlfferen!): �� .
<br /> CouMy:�Gys�1,.�1�..�. Property owner phona: �• ? - ov fl Permitting auihority: G}�.� o���
<br /> Date system constructed: ��¢ �q R�, Reason for Insp cUon��k��(���y�.
<br /> System Desc�lption
<br /> Brief systom descriplion: _� -1 oDp��S1 I. �i�q�ytiy�,� �5y� — yy14 y�p 10�9 P�?�
<br /> Local permit number. _„ � � Number of bed ms: ,,,�� Design flow rate: �pDv __ �
<br /> Is trie system: �
<br /> in Shoreland area? ❑Yes � No In Ilhead Protecbion Aree9 ❑Yos � No
<br /> An U.S. �nvironmental.Protection Sys m serving a Minnesota peparlment
<br /> Agency(EPA)Class V In]ection WeII?�Yes �No of H ath(MDW)Ii��nsed faciliiy? ❑Yos � No
<br /> Corilpll'711�e $tdtUs(8ased on stake tequirements—addfUona loc�al requirements may also apply,)
<br /> 6ased on the infocmation gathe�ed and report�d on aitached form ,the compliance status of this aystem is(dieck one):
<br /> ■Certiflcate of Compliance—valid untll(3 yoars tram datrs of rep r�:
<br /> ❑ Notice of Noncompliance-For Noncompliant syetems:
<br /> ThE reason fvr noncoRtplience ls:
<br /> Yhls noncompllant system is cla�sifled as�heck one b low):
<br /> ❑ Imminent threat to publlc health 8�safety Failing to pl otect ground water ❑Not in compllance with operatfng permit
<br /> CertlfilCdti011(Completed form must be submitt�d to the local u it of govarnment within 15 days,)
<br /> !liereby certlfy that all the neccssary infom�ef/on has been gathe d to determine the compllance status of this system. No
<br /> det�rmination of/Uture system p�rformence h�s boen nor can be ade duo to unlmqwn conditions during systam cons#ruction,
<br /> possibie abu5e of the syStem,inedequai�e maintenence,or futu� ter usage.
<br /> NAme: ������ �.����.�� „ Certiflcafion number. �,;�,,� y
<br /> Business licanse neme and number: 'S —�' -���ri1�, ►(�� �� 4 � ,� ,,
<br /> 9 ,—_..;,��a���2�I�,Sc. or
<br /> Name of local un;t of gov mment:
<br /> .�,.
<br /> Signature: � . � �ti----� � Date• • rp M ^�
<br /> Required AttacNments Inspector ompiote:This lnspection Report is � pages lon8.
<br /> Check corriplianco inrms attached: I�Hydraulle Parfomtance � enk Integ�lty �Soll SAparedon p Oparetlng Pennit Form(If
<br /> applicable) �System drawing/Ao-built drawing ❑An eesessmont o any bcal requlrements lhat ere ditierent flnm whPt is required on this
<br /> [orm �Soii Boring Lops ❑AbQf�dohment form(if approptiato) ❑ her I�fonnatlon(Iis!):
<br /> �Jpgrade Requir�ments(derlvlwead from IVhnn.Stat§�15.56)An hn ��enl(A�af fo pubpc hea�h nnA sofely(l7YH3)muaf be uppredeol,re�eced,or
<br /> Ifa use d/sconNnued►a1(ry/n t�n monfha oF�eeelpr of thls nofJbe or uwlhln p shortei 7requlred bylocal wdlnena.If the system la PapNtq to p�pf6Ct pra�nd
<br /> weler,fhe�system must be up,q�dod,rapleoed,or If8 uso d(SconNnued w/1hlp the Ims requl�d by�cal Ordlnence./I sq CXlsfhfp sysfem fs nof fe/Nng ps deRnerd/n
<br /> lew,snd ha5 9t/eesf(wo fe9t 0/dea/pn erAp se/�rdHon,Hlen thR t�tem need be upg�ded,rspgl�nd,rep�aCad,or�s�sR dlseonfGtued,nWW!(hslendlnp e►ry
<br /> foeal oN/neoeis mat/s more�atKcf.Thls provlalon does not apply(o syxt�ms!n end neQps,W�ho.�d Profaay/on Ilre�a,or�hase uaed/n eonneeHon wpyi lpod,
<br /> bevcragre,end bdAqrg sslabqshmails os d�fmad in law, '
<br /> wq-wwlsrs4-3� CompFiance Inspectlun Farnr for Eicistfng SSTS
<br /> q!1/08
<br />
|