Laserfiche WebLink
r .� <br /> ►utinnesota Poiiution Compliance Inspection Form <br /> - Control Agency <br /> 52a LafayeYte Road North Existing Subsurface Sewage Treatment Systems (SSTS) <br /> St.Paul,MN SS155-4194 Doc Type:Compliance and Enfor�ement <br /> RECEIVED <br /> InspeCtion results based on Minnesota Pollution Control Agency(MPCA) For local tracking pu�SZ � 101� <br /> requirements and attached forms—additional local requirements may also apply. I <br /> Submit completed form to Locai Unit of Government(LUGj and system owner cfN�F dR�NO <br /> within 15 days � <br /> System Status <br /> System status on date(mm/ddlyyyy): 3J20/2016 <br /> ❑ Compliant— Certificate of Compliance � Noncompliant— Notice of Noncompliance <br /> (Valid for 3 years from report date, unless shorter fime (See Upgrade Requirements on page 3.) <br /> frame ouflined in Local Ordinance.) <br /> Reason�sj for noncompliance(check all applicable) <br /> ❑ Impact on Public Health(Compliance Component#1)—Imminent threat to public health and safety <br /> ❑Other Compliance Conditions(Comptiance Component#3)—Imminenf threat to public health and safety <br /> �Tank Integrity(Compliance Componenf#2)—Failing to protect groundwater <br /> ❑Other Compliance Conditions(Compliance Component#3)—Failing to protect groundwater <br /> � Soil Separation(Compliance Componenf#4)—Failing to protect groundwarer <br /> ❑Operating permit/monitoring plan requirements(Compliance Component#5)—Noncompliant <br /> IY <br /> Property Information �i����7�� Par�ei i�#or se�rrwPiRan9e: __ <br /> Property address: 4380 Co ` ac�6 Long Lake MN Reason for inspection: Property Transfer <br /> � C <br /> Property owner: Bank Owned Owner's phone: <br /> or <br /> Owner's representative: Dan Moore Representative phone: 763-232-6990 <br /> Local regulatory authority: City of Long Lake Regutatory authority phone: <br /> Brief system description: Tank has no bottom. Redox at 18" <br /> Comments or recommendations: <br /> Mound system needed. <br /> Certification <br /> 1 hereby certify that al!the necessary information has been gathered to determine the compfiance sfafus of this system. No <br /> determination of future system performance has been nor can be made due to unknown conditions dunng system construction, <br /> possib/e abuse of the system, inadequate maintenance, or future water usage. <br /> Inspector name: Chad Lashinski Certification number: C3054 <br /> Business name: Residential Testi � s License number: L3636 <br /> Inspector signature: Phone number: 612-991-7044 <br /> Necessary or locatly Required Attachments <br /> � Soil boring logs � SystemlAs-built drawing ❑ Forms per local ordinance <br /> � Other information(list): Additional Terms _ <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in atternative formats <br /> wa-wwrsts4-31 • 3/16/11 Page 1 of 3 <br />