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��, <br /> Minnesota Pollution � Compliance Inspection Form <br /> Control Agency � I <br /> It1 /l Existing Subsurface Sewage Treatment Systems <br /> 520 Lafayette Road North 7 <br /> st Paul,MN 55155-0194 �/�/ (SETS) <br /> Doc Type:Compliance and Enforcement <br /> Instructions: Inspection results based on Minnesota Pollution Control Agency(MPCA) For local tracking purposes: <br /> requirements and attached forms—additional local requirements may also apply. <br /> Submit completed form to Local Unit of Government(LUG)and system owner <br /> within 15 days <br /> System Status <br /> System status on date(mm/dd/yyyy): {� <br /> YK Compliant—Certificate of Compliance ❑ Noncompliant— Notice of Noncompliance <br /> (Valid for 3 years from report date, unless shorter time (See Upgrade Requirements on page 3) <br /> frame outlined in Local Ordinance.) <br /> Reason(s)for noncompliance(check all applicable) <br /> ❑ Impact on Public Health (Compliance Component #9)—Imminent threat to public health and safety <br /> ❑Other Compliance Conditions(Compliance Component#3)—Imminent threat to public health and safety <br /> ❑Tank Integrity(Compliance Component #2)—Failing to protect groundwater <br /> ❑Other Compliance Conditions(Compliance Component#3)—Failing to protect groundwater <br /> ❑Soil Separation(Compliance Component #4)—Failing to protect groundwater <br /> ❑Operating permit/monitoring plan requirements(Compliance Component #5)—Noncompliant <br /> Property Information /� Parcel ID#or Sec/Twp/Range: <br /> Property address: .4119 ,�y f ry 1A Reason for inspection: Y4 je. <br /> Property owner: Owner's phone: <br /> or <br /> Owner's representative: Representative phone: <br /> Local regulatory authority: C, f' m/7p A.�0 Regulatory authority phone: <br /> Brief system description: A m uy <br /> Comments or recommendations: <br /> Certification <br /> I hereby certify that all the necessary information has been gathered to determine the compliance status of this system. No <br /> determination of future system performance has been nor can be made due to unknown conditions during system construction, <br /> possible abuse of th.P system, inadequate maintenance, or future water usage. <br /> Inspector name: pA e,y Certification number: �,t6 <br /> Business name: n t-4 0 &$A I I f -Lvte o--w sZALicense number: J <br /> Inspector signature: Phone number: 7Gc�7Q <br /> Necessary or Locally Required Attachments <br /> [I Soil boring logs ❑System/As-built drawing ❑ Forms per local ordinance <br /> IV Other information(list): n N ti r t' <br /> www.pca.state.mn.us • 651-296-6300 800-657-3864 TTY 651-282-5332 or 800-657-3864 • Available in alternative formats <br /> wq-wwists4-31 • 1124112 <br /> Page f of 3 <br />