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02/06/2009 10:19 7634275934 SYSTEM SOLUTIONS PAGE 02 ...... ......e Minnesota Pollution� compliance Inspection Form , ec- Control Ag• n y 520 Lafayette Road North Existing Subsurface Sewage Treatment Systema (SSTS) St.PaUL MN 55155-4194 Parcel number: For Local Tracking Purposes: System status: Compliant El Noncompliant (based on all co b nee requirements) Summary Form Property Information Property owner name(s): G•es�/��- l r - Property address; �' J� ly .rT1 /t e ClC=`14 0age Property qwpees qddress(If different): County: Property owner phone: Permitting authority: Date system constructed: Reason for inspection: Rg19.. System Description , Brief system description: Local permit number: Number of bedrooms:Design flow rate: Is the system: In Shoreland area? ❑Yes No Irk Wellhead Protection Area? ❑Yes;.&No An U.S.Environmental Protection System serving a Minnesota Department Agency(EPA)Class V Injection Well?❑Yes No of Heath(MDH)licensed facility? ,❑Yes ,TNO Compliance Status(Based on state requirements—additional local requirements may also apply.) Based on the information gathered and reported on attached forms,the compliance status of this system is(check one): Certificate of Compllanc®—valid until(3 years from date of report): _ ❑ Notice of Noncompliance-For Noncompliant systems:' The reason for noncompliance is: This noncompliant system Is classified as tcheck one below): ❑imminent threat to public health&safety Li Failing to protect ground water ❑Not In compliance with-operating permit', Certification (Completed form-must be submitted to the local unit of government within 15 days.) I hereby certify that all the necessaryinformation has been gathered to determine the compliance status of this system.No determination of future system performance has been rior can be made due to unknown conditions during system construction, possible abuse of the system, inadequate maintenance, or future water usage. .(shone: 763-427-59 4 Name: . C VIC HAGENAH -15231 Jackel St. N Business lipense name'and number: SYSTEM SOLUTIONS_Ramsey, MN 5530 Name of local unit govern nt: el (� MPCA#1483 Signature: Date: Required Attachme s Inspector Complete:This Inspection Report'ls pages long. "Check compliance forms attached.grHydrowe PerformanceTank Integrity ❑Still Separation C)operating Permit Form(ii applicable) ❑System drewinglAs-bul drawing ❑An assesimen of any local requirements that are different from what is required on this form ❑Soil Boring Logs ❑Abandohni'enr form(N appropriate) ❑Other lnfonnetion(fist): Upgrade Requirements(derived fmm Minn.Slat§118.58)An Imminent threat to public hash end safely frrPH8)must be upgraded,mobeed'or is use dlaconlinved within fen months or recelpt of tMa rmt/oe or wth/n s shorter period IFrequhed by We/odinance.it the eyalem Is faAMg to prated ground. water.rho system must be upgrodad Mooed.or sir Use disconRnved within the time regtdred by boat ord norica.Iran v0stMd syst*m,is not►*flog ss;defined In Isw,and heir of least two feet of design soil soperef/on,then the sysfam need not be upgraded,repaired,replaced,or He use dacord/nued,nofwthsfantling airy local ordMwrrce that is more saki. This pmWv Ian deet net apply to systems In shomiand areas,Wiellhend Protection Areas,or those used in conneotitm wlrh food, beverage,and lodging estabgshments as detned/n few. I