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� r � �`�� AJlinnesota.Pollution �� C pliance Inspection Form Controt�1r��ncy �� 5�t7 Lat'ayette Rnad North � `� ting Subsurface Sewage Treatment Systems st�aur,��1 s�ss-a�sA /'1,� (SSTS) `�U Doc Type:Compliance and Enforoement Instructions: Inspection results based on Minnesota Pollution Coritrol Agency(MPCA) For local tracking purposes: requirements and attached forms=additional local requirements may also apply. Submit completed form to Local Unit of Govemment(LUG)and system owner within 15 days System Status System status on dat�e(mm/ddlyyyy): .�o O ?� �mpliant-Certificate of Compliance ❑ Noncompliant-Notice of Noncompliance (Valid fi�r 3 years finm report date, unless shorter time (See Upgrade Requi�ments on page 3) frame outlined in Local ONinance.) Reason(s)for noncompliance(check alI applfcable) � � ❑impad on Public Health(Compliance Component #1)—lmminent threat to publ'rc hea/th and safety ❑Other Compliance Conditions(Compliance Component#3)—Imminent threat to public healti►and safety ❑Tank Integrity(Comp/iance Componenf #2)—Failing to pr�tect graundwater ❑Other Compliance Conditions(Compliance Component�1,3)—Failing to protect groundwater ❑Soil Separation (Compliance Component #4)—Failing to protect groundwater ❑Operating permiUmonitoring plan requirements(Compliance Component #5)—Noncompliant Property Information Parcel ID#or SeclTwp/Rarrge: Property address: ��/.f �;� ��, /V, Reason for inspection: - Property owner: Owner's phone: or Owners representative: Representative phone: Local regulatory authority: �� m IQQ,�/�� Regulatory authority phone: Brief system description: /=f,�.,,� ��T� �+� �,4,,�k /Dw�4.�./ � �q�,,.....i, ��[.. Jj{s.�.�.,,�S.S,fJ�i,y. Comments or recommendations: /o'x y/' ��,�fC ,�O Certification l hernby certify dhat al!the necessary infoRnaSon has been gather�d to determine the compliance status of this system. No determination of futuie system perfoimance has been nor can be made due to unknown condiNons during system construction, possible abuse of the ystem, inadequate mair�tenance, or futu�water usege. Inspector name: �,� Certfication number: ?'�� Business name: t o : ...� �'�.r,.,,�,� License number: ,� / Inspector signature Phone number: Necessary or Locally Required Attachments ❑Soil boring logs ❑SysteMAs-built drawing ❑Forms per local ordinance ❑Other information(list): www.pca.state.mn.us • 657-296-6300 • 800-657-3864 • TlY 651-282-5332 or 800-657-3864 • Available in altemative formats wq-wwfsts431 • i/24/12 . Page.l of 3