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��� <br /> � 4_• a \� <br /> `J� ���i, . <br /> � Minnesota Poilution � Compl�ance Inspection Form <br /> Control Agency <br /> 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems (SSTS) <br /> St.Paul,MN 55155-4194 Ooc Type:Compliance and Enforoement <br /> __ _. __._.-- ---- <br /> Inspection results based on Minnesota Pollution Control Agency(MPCA) i For local tracking purposes: ' <br /> requirements and attached forms-additional local requirements may also apply. <br /> Submit completed fom►to Local Unit of Government(LUG)and system owner �I <br /> within 15 days _._�__� <br /> System Status <br /> System status on date(mm/dd/yyyy►: 8/6/2012 <br /> � Compliant— Certificate of Compliance ❑ Noncompliant— Notice of Noncompliance <br /> (Valid for 3 years from report date, unless sho►ter time (See Upgrade Requirements on page 3.) <br /> frame outlined in Local Orclinance.) <br /> Reason(s)for noncompliance(check all applicab/e) <br /> ❑ Impact on Public Health (Compliance Component#1)-Imminent threat fo public health and safety <br /> ❑Other Compliance Conditions(Compliance Component#3)-lmminent thieat to public health and safety <br /> ❑Tank Integrity(Compliance Component#2)-Failing to protect groundwater <br /> ❑Other Compliance Conditions(Compliance Component#3)-Failing to p�tect groundwater <br /> ❑ Soil Separation(Compliance Component#4)-Failing to protect groundwater <br /> ❑Operating permiUmonitoring plan requirements(Compliance Component#5)-Noncompliant <br /> Property Information Parcel ID#or Sec!'fwp/Range: <br /> Property address: 4225 County Road 6 Orono Reason for inspection: Property Transfer <br /> Property owner: Bank Owned _ Owner's phone: ___ <br /> _ _------ - ___— <br /> or <br /> Owner's representative: Ryan Johnson Representative phone: 612-816-5764 <br /> -- <br /> Local regulatory authority: City of Orono Regulatory authority phone: ____ <br /> Brief system description: 2_1000�allon_tanks, 1000 gallon lift station, mound system <br /> __ _ -- . --- — � <br /> Comments or recommendations: � <br /> \ <br /> � <br /> �� <br /> Certification <br /> 1 hereby certi/y that all fhe necessary infom►a6on has been gathered to determine the compliance stafus of fhis system. No <br /> deferminaGon of futuie system performance has 6een nor can be made due to unknown conditions during system construction, <br /> possible abuse of the system, inadequate mainte , or future water usage. <br /> Inspector name: Chad Lashinski __ ___ Certification number. C3054 <br /> Business name: Lashinski Sep' __ License number: 65 <br /> Inspector signature: Phone number: 612-991-7004 <br /> Necessary or Locally Required Attachments <br /> ❑ Soil boring logs � SystemlAs-built drawing ❑ Forms per local ordinance <br /> ❑ Other information(list): _ <br /> _ --- __- _ ___ _. --- --- <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats <br /> wq•wwists4-31 • 3/16/12 Poqe 1 oj 3 <br />