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, Mar. 28, 2013 1 ;45PM � No. l�l� P. 3 <br /> • � � � <br /> ' �. - �N(I`t�nesota Pollution ,� �Q���i�,��� {��p��tion Form <br /> ,,_,��:�,���,� <br /> ry Control Agericy �r � Existing Subsur#ace Sev++age Tre�tment Systems <br /> `'�, `'��:� 1 <br /> 520 La�ayeCte Road North I �SST$� <br /> 5�P�u1,MN 5 51 5 5-4194 � <br /> poc 7ype:Complrance and�rrlorcement <br /> For local t�acking purposes: <br /> Instruations: Inspectlon results based on Minnesota Pallutlon Cvntrol Agency(MPCA) , <br /> requiremenEs end ettached forms-additional 1oc$l requirements may also�pply. , <br /> $ubmlt completed form to Local Unit of(3ovemment(LUG)and gysb�m owner <br /> withln 15 days <br /> System Status <br /> System statu$oo date(mtttlddlyyyy): <br /> �Compltant-Certificate of Compli�nce ❑ NoncomRlian#-Notice of Noncompii�nce <br /> (Velid for 3 years from r�eport date, urtless sho►ter Cme (See Upglade Requ7r�ments on pdge 3) <br /> freme outffnad in l.oca!OrUlt�anca.) <br /> Reason(s)for noncampllance(chack al!appllcable) � <br /> [�ImpaCt on Public Health(Complrence Compon�nt #1)--fmminent ih�eat fo public heafth and safety° <br /> �]01her Compllance Conditions(Compliance Component#3)-lmmrnent threat f+�pubfic healfh and sefety <br /> ❑7ank Integrity(Compliance Compon9nt #2)--Failing to protect groundweter <br /> �]Othar Compllance Condltlons(Campllanc�Component#3J-�aili�g to pmf�ct groundwater <br /> ❑Soi1 Separatlon{Compllanc�e Component #4)-Fa�ling to protect groundwater <br /> ❑Operatlng permwmonitodng plan requl�ement�(Comp!lance Componenf #.5)-Noncamplfant <br /> praperty Information Par�l 1DJk or Sec!"fwplRange: �r� . ��� .� <br /> �roparty eddreas: ti � � �� ReaBo�ior Inspection: -. <br /> PropertY owner: � _ Owners pftone: � <br /> or � <br /> pwner's represantative: � �� Represantaiive phone: ba'�-q� - o <br /> Locel regulatory�uthority: G�-� � a�v � Regul�tory authority phone: q S a-a,�}q -�4S�Q__ <br /> Briet system desC�iption: - � -� L �`��^^� �"`� � � <br /> Comments or recommendaUons: yl���(�;,�' �2pL`�"�`-� �s�Z.F�w ��'� � ����'��'� ��'�� <br /> , � , . . <br /> Certifjcation <br /> !her�by certiry that al!the necessary information hes been gathered to detenn�ne fhe Compllenoe status of this system.No <br /> dete►minstion or futUr�systefn perfiormance has bean►1or Can be made due to unfmown catdltfona during system consfrucflon, <br /> possible abuse of fhe system,lnadequete melnt�enence,orfuture watar useg�. i <br /> lnspeclor name: r/ L� Ceclificati�n number: (d. '� <br /> Busin�ss name� 5 �' � Llcs�se numbar: <br /> lnspector slgneture: ..-•� � . Ph �ne number: �1�� f��t�?v� (o — <br /> a or �ocall Re uired Attachments i <br /> Necess ry Y Q � <br /> �Soll boring logs ■SyslamlAs-buflt drawing (]�orms per fac�l ordlnance <br /> ❑Other information(list�: I <br /> � <br /> �rv�w.pca.s�ace.mn.us • 651-246-63�0 • 800•657•3864 • TTY 651-182•533Z or 00-657�3864 � AvAjldble tn altemative formdts <br /> wq-w►vfsfs431 • i!?4/12 <br />