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_ . 07/18/296� 1:58 7634975011 SPTESTINGINC PAGE 06l10
<br /> �.:,:..:,;;:...::.:.. ,�;� n o� Po���r�on � Com liance Inspection �Form
<br /> ,=,�� p
<br /> . Co�t IAgency �
<br /> ce Sev�ra e Treatmen# Systems (SSTS)
<br /> sao��,F �ete Road North �Mp�t'ng Subsurfa 9
<br /> � St�aul, N 55is5-a19a Instructions on page 7
<br /> Parcel numb¢rl� , _ For Local Tracking Purposes:
<br /> System status:l Compllar�t ❑Noncompllant
<br /> (based on all cpm llanc�requirements)
<br /> Su�nmary I�
<br /> Property Ir�f �mation
<br /> Property uwmer �m�(s): ��,. +�`w`^ ,
<br /> Property adc�res ; 3a�-S 51►-�5�-� d• n�-� -
<br /> Property ow�er raddress(if different): .� --- ---
<br /> County: .� ',�_ Property owner phone: (�j�-$o�- 7a3�.. ._ Permltting authoMty: �f�(?�,I`1�0
<br /> Date syste co 8�u�: � Reason for inspectlon: _,,,��.��'�- .w_.
<br /> System De�c ption
<br /> Brief systeml de �Iption= ,��5+�+�f�z'� ��`�"� � ---r
<br /> Local pemnitlnu ber: J • ,,.�,_ Number of bedrooms: Design flow rate: _„_,�
<br /> Is the syste�:
<br /> t�Shorel d rea? ❑Yes � No In Welihesd Protection Area7 Q Yes �No
<br /> An U.S.E�vir nlllentsl Protscfion System serving a Minnesota Department
<br /> Agency(�PA Class V InJection We l l?[]Yes �N o o f H e a t h(M D H)l i ce n s e d f a c l l l ty? (]Y e s �N e
<br /> COT17pI1a�C d�US(Based on state requirements—edditional local requiremenls may also apply.)
<br /> Based on th In nnation gathered and reported on attached forms,the compliance status of this system is(check ona):
<br /> �Certifica of�ompliance^velid untll(3 years trom data of report): _ y l'$ ,.011
<br /> 1
<br /> ❑ Notice of,No �ompliance-For NoncompliaM systems:
<br /> The re so for noncompllance is: ,
<br /> This n�� mpliant system is classified as(c-heck one below):
<br /> ❑Imr�in threat tb public heaRh&safety ❑Falifng to protect ground water (] Not in vompli�nce with operatiing permit
<br /> Cert�fieati�tl �ompleted form must be submitted to the Iecal unit of govemmant withln 15 days.)
<br /> 1 hereby cer�lfy t all the necessary Infiorma6an hes been gathered to det�ermine the compliance status of this system. No
<br /> determinetf o I�utu►e system performence has been nor Can be mede dua to unknown cvndit,iAns during system constructian,
<br /> possible ab se f the system,inadequate meinfenance, or futuna water usage.
<br /> Neme: . _s�'�Q�►,!�'�S ,_ Certification number: (o��_�
<br /> Business lic ns �name and number: 5 ,.:���j:.?�`J�'.L� ��'�i��.�ta� '�q�''3`��r- °r
<br /> Name of loc�l u of government: , . --
<br /> Slgnalure: ' _ ,. Dete: ,� ����`g�b�
<br /> Required tfi chments ►nspectar Complete:Thl�Inspectlon Report is��ages long.
<br /> CheCk Com Na be fotms attached: �Hydraulic PerFormance �Tank Integrity �Sotl Separatiop ❑Operating Permlt Form(IF
<br /> appllcable) $yatem dtawinglA�-bullt drswing ❑An easessment of eny local requlrements khak are difEerent from what is required on this
<br /> fortn [�I S il B ting!-ogs ❑Abendonme�form(IF appropriate) G]Other i�orm�tlon(Ilst):
<br /> U pgrad RR Ire ^�m��. ( ed rlved 1in►n AMnn.S(s!.§115.66)An immMen!tMAaf lo puCllc hee/fh and saf�ty(ITpHS)musf De uppndec�,�eploced,or
<br /> !te use dlscpnttn tl Wf(hfn ten monNls bf recelpt of fh18 nodco or wlM1ln a sho►ter pe►lotl if►aqupM by/ocel o►rlinAnec.1/fhe sy9tem i6 fpillng!o protect pround
<br /> weter,tne s�rs�e i►nust b�uppreded,rep►aced,orlla uee dlsconUnucd wlfhhi fhe Eimv raqulrRd 6y�ocal ortllnonce.!I an exlslUp system!�not feApfp ea deNned In
<br /> law,and h at fwo feef of des�Bn�i7smPe�Non,f�en!A�system neeal no1 Ue up�g►aded,r�polred replaced,or Rs oso dlsconfMued,noMNfhsfandlr�p any
<br /> rocal ord/ne pf�s more atNct Thl�p►ovlafon doss not appty to systoms h�ahoreland arr.ne,WetlAead�rolecNon Neea,or Mioso ueed!n connecrlon wMi faod,
<br /> lnverepe, nd 1 Inf1 esfebllshm¢n!3 as defined M law,
<br /> wq-wwists4-3� CompNfance Inspection Form for�xistfng 55T5
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