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764-'13-0695 p.1 <br /> Minnesota <br /> ota Pollution Compliance inspection Form <br /> Minne <br /> Agency <br /> SM6affyoupPleadNorth illbNf♦�NtwoMP TMNfII wA 81 men 1a <br /> St Paul,NN SS1'5.4194 ism) <br /> 1+8trucl7ons: Insptsdon renN a Dew.on Mrinmia Pclhrtion Control Agerxy�MPCA) �Fo-r' 1'. .,c►,:,p Put., -- -----� <br /> requirements and attached forma-addr onal bral requirements may also apply. <br /> Submit- Plated torn to Local Unit oti Govemme t(LUG)and system owrw- <br /> within i6 days <br /> Sysiern Status <br /> Sysbm status an date(mmMdlyyyy): <br /> Compliant-Cerdficeft of CotnpNance Cl Hall=, pliant -Notice of Noncampliance <br /> (Valid kr 3 yearn liar spat data, uNwss sho►tartime (See Upgrade RagL,re,-jenft on page 3) <br /> harm outrAw in tooaf On MrWrice.) <br /> Resson(s)for noncompliance(chock aN epplicaW <br /> 0 Impact on PubUC Msmhh(CorWisaee Canp*wN 07)-•)mminant"Irw to pubk 1 -a119,.Ynd sale•y <br /> Q Other Compliance Conditions(Contpparrce Co 7wnent 43)-hnmlrrw:`tAreaf.o p...'c hookh and Wsly <br /> ❑Tank Integrity(CorrWama Cornparvent 02)-Fadksp to pralW grow+awsler <br /> ©Other Compliance ConddWorla(Cor*ft&me COMPOnag#3)•-Falliing k,,ifWect prc.jr,.ivraler <br /> ❑Soll Separation(Compllence carrwnert 04)-Faft to pn ffia!peau•:C►pm1ar <br /> Q 01mralling painiVoxaftinig pWn requiletnanla(Corrrp7ance Carwrwt:' ti+r'-Nana•oh:-nr <br /> Property InformationParaal 1t7t1 or Seen*WR _ <br /> Property address: }a•Keeson for Beep- .!ion: <br /> Property owner: _ owners phone: <br /> or <br /> Owners reprersenWUYe: __ Repreaentmive phone L <br /> Local regulatory authority Rei aulhor2y l rcr, G r1• � - �5' <br /> Brief system description: <br /> Comments or rscomrnandadars: <br /> Certification <br /> I hereby cojOy that as the nevowery information has been ptAwad to derermsne the co npliarve AM. i AL4 system. ht <br /> detera neWn offutura syWom perfamance nes been nor con be meds dire w unlurown condit/o•, due 1WIV77 wnatru0r-1"' <br /> possible abuse of the system.,hwdequate malnio7ows,or flrtunf water usage _ <br /> Inspector na;ne: -,_. CertiRartbn numbe <br /> Business name �.! .. Licence number _�..!r3, --- <br /> Inspector signature: : Phone number: l <br /> Necessary or Locally Required Attachments <br /> P0 Soil boring bps %LSyslarNAs-bulll drawing VForms per hese ordinance <br /> Q Odw informed=tlist) �.._... ... ..,R�.. ._ <br /> www.pca,sTate.mn.us 651-2964300 • 1100-657-1x64 TTY 651.2ti2•5312 or MX)-457-3&d • Avafla tlt in alt: rWive fo."ar. <br /> wq-wwfdA-31 . 1/24)12 Ade IV/3 <br />