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���,��� Minnesota Pollution <br /> ��� »� Compliance Inspection Form <br /> : Control Agency <br /> 520 Lafayette Road North Existing SubsurFace Sewage Treatment Systems (SSTSj <br /> St.Paul,MN 55155 4194 Doc Type:Compliance and Enforcement <br /> InSpeGtion results based on Minnesota Pollution Control Agency(MPCA) For local tracking purposes: <br /> requirements and attached forms–additional local requirements may also apply. aDD � � �O�� <br /> Submit completed form to Local Unit of Government(LUG)and system owner f �� <br /> within 15 days <br /> i- <br /> System Status <br /> System status on date(mm/dd/yyyy): _4/13/2015 <br /> � Compliant—Certificate of Compliance ❑ Noncompliant— Notice of Noncompliance <br /> (Valid for 3 years from report date, unless shorter time (See Upgrade Requirements on pape 3.) <br /> frame outlined in Local Ordinance.) <br /> Reason(s)for noncompliance(check a/l applicable) <br /> ❑Impact on Public Health (Compliance Component#1)–lmminent threat to public health and safety <br /> ❑Other Compliance Conditions(Compliance Component#3)–Imminent threat to pu6lic heafth and safefy <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 permiUmonitoring plan requirements(Compliance Component#5)–Noncompliant <br /> Property Information Parce)ID#or Sec/Twp/Range: 28-118-23-41-0004 <br /> Property address: 2500 SIXTH AVE N Reason for inspection: SALE <br /> Property owner: LEW A ERICKSON Owner's phone: 612-990-5292 <br /> or <br /> Owners representative: Representative phone: _ __ <br /> Local regulatory authority: City of Orono Regulatory authority phone: (952)249-4600 <br /> Brief system description: Two tanks lift tank,mound <br /> Comments or recommendations: <br /> Certification <br /> 1 hereby certify that all the necessary infonnation has been gathered to determine the compliance status of this sysfem.No <br /> determination of future system performance has been nor can be made due to unknown conditions during system const�uction, <br /> possible abuse of the system, inadequafe maintenance, or future water usage. <br /> Inspector name: Chris Berq Certification number: C9523 <br /> Business name: Techtron Enqineerinq,Inc. License number: L1172 <br /> Inspectorsignature: �.--'",__–.'�_} _,_..—�-`'�..�.__� Phone number: (763)712-9502 <br /> �S <br /> Necessary or Locally 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 • Availablein alternative formats <br /> wq-wwists4-31 • 3/16/12 Page 1 of 3 <br />