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Mar 21 2 04:46p ^�� 763-213-0695 p,1 <br /> • , � \� <br /> � � � �� <br /> Minnesota Pol�uron `� � � Com tiance Ins ection Form <br /> - Control Agenty /�.� P P <br /> 5Z0 Lafayette Road North ���9 �bsurface Sew�ge Tr�trnent Systems <br /> St.Pau�,MN 55i55-4�94 (SSTS� <br /> Doc Type:Compliance arxi Enfomement <br /> Inst�uctians: inspection resulis based on Minnesota Pollution Conlrol Agency(MPCA) For lacal tracking purposes: <br /> requ#remer�ts and attached forms—additionai iocal requirements may also apply_ „ ' Q �— �n/� <br /> Sub it completed form to Local Unit of Go�ernment(LUG)and system owner o �i U <br /> with�n 15 days <br /> Syslem Status <br /> �System status on date(mm/ddlyyyy): 3 .r j�' — �'�-- <br /> II� Compliant— Certificate of Compliance ❑ Noncvmpliant— Notice of Noncornpliance � <br /> (Valid for 3 years from report date, unless shorfer time (See Upgrade Requiremenfs orr page 3) <br /> frame outlined in Loca!Ordinance.) <br /> Reaso�(s)for noncompliance (check a!1 applicable) <br /> ❑ Impact on Public Health (Complisnce Component #1)—Immrnent threat to public health and safety <br /> ❑ Other Complianoe Conditions(Compfrance Component�3)—lmminent fhr�at to public health and safety <br /> ❑Tank Integriry(Oomp/iance Comporrenr #2)—Farlrng fo pr+otectgroundwater <br /> ❑Other Complianoe Conditions (Compfiance Cormponenf#3)—Failing to pmtect groundwater <br /> ❑Soil Separation (Compliance Component #4)—Failing to protect groundwater <br /> ❑Operating permit/monftoring plan requirements(Comp/iance Component #5)—Noncompliant <br /> P�O I@rt)/ �I1f01'lilatlOn Parcel ID#or Sed'fwp/Range: <br /> Prope address: � Reason for inspection: <br /> Prope owner: ' Owner's phone: <br /> or <br /> Owne s represeni�tive: �,��, ����{ Representaiive phone: �lj� � ;�.q`3.-j y �, ( <br /> Local �latory authority: � �� Regulatcry authority phone: <br /> Brief s stem description: ' �D � ' <br /> Com nts or recammendaiions: <br /> , �� <br /> Certi ication <br /> 1 here certify that aN the necessary infarmatron has been gathered to deteimine the compliance stafus of this syste�. IVo <br /> dete 'nation of/uture system perfnrmance has been nor can be made due to unknown conditions during system construetron, <br /> possi abuse of fhe system,inadequat mainfenance, or fufure wafer usage. <br /> Inspe r r�ame: ����c d � Certification number: � �' �� <br /> BLsine narne: _ �- -�j �,�.d•�p D-c� � License number: �j �j 3 <br /> Inspe rsignature: __� �z�y,�t�v1����a,�.'� Phone number. '�f_,�l,/ —'.,�.1,� <br /> Nece sary or Locally Required Attachments <br /> (�S il boring bgs �Sysfem/As-built drawing ��Fortns per local ordinance <br /> ❑ O er information (list): <br /> www.p .state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657•3864 • Available in alternative formats <br />