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09/30/2010 01:02 7634975011 SPTESTINGINC PAGE 04111 <br /> � <br /> ;:. . <br /> Minnesota Pollution <br /> Control Agency COmpliance Inspection Form <br /> 520 Lafayette Road North EXIStinlg Subsurface Sewage Treatment Systems (SSTS) <br /> St.Paul,MN 55155-4194 Doc Type:Gamplience and Enforcement <br /> Instructions on page 6 <br /> Summary Form (Completed form must be submitted to the local unit of government within 15 days.) <br /> Parcel number: <br /> System status: d Compliant ® Noncompliant - For °cal T acking Purposes: — <br /> (based on all compliance requirements) <br /> Property Information -- — <br /> Property owner name(s); �F Property owner phone: f jJt� <br /> Properly address: <br /> Properly owner address Of differa;nt): . — <br /> County: - <br /> � s3�t Permitting authority: <br /> Date system constructed: Reason for inspecgon:,, <br /> System) Description <br /> Brief system description: <br /> _2-1c9„dd gyal.`+�� yL � ,�► '�LM ,�tt�31�^ 1 DrK.S�Fs�r�*�7d <br /> Local permit number, _ Number of bedrooms: _ Design now rete: <br /> �o <br /> Is the system: -- <br /> In Shoreland area? ❑Yes 'IN No In Wellhead Protection Area? <br /> ❑Yes 0 No <br /> An U.S. Environmental Protection System serving a Minnesota Department <br /> Agency(EPA)Class V Injection Well?❑Yes, X No of Heath(MDH)licensed facility? ❑Yes ®No <br /> Compliance Status(eased on slate requirements-=additional local requirements may also spply,) <br /> Based on the Information gathered and reported on attached forms,the compliance status of this system is(check one): <br /> Certificate of Compliance-valid until(3 years hom date of report): <br /> Notice of Noncompliance-For Noncompliant systems: <br /> The reason for noncompliance is; <br /> This noncom liant ( — <br /> p system Is classlfi®d as(check on®.below): " <br /> 0 IIm'`mi�nenl��t to public health&safety 49 Fading to project ground water ❑ Not in compliance with operating permit <br /> Certification <br /> I hereby certify that all the necessary Infoimsfion'has been gathered to deterrrmre the compliance status of this system. No <br /> determination of Mire system performance has been nor can be made due to unknown conditions during system construction, <br /> Possible abuse of the system,inadequate maintenance, or future water usage. <br /> Name: ��/ 1 M 5_. _ Cerlificaikon number: (o <br /> Business license name and number: 111C-1 L or <br /> Name of local unit off-gover ent: <br /> Signature: J? ..� �' -.... Dale: _ .na1Q. <br /> Required Attachments <br /> ® Hydraulic Performarice Tank Integrity Boll Boring Logs 98oll Separation ' Q Ap@rating Permit Form(if applicable) <br /> ® <br /> System drawing/As-built drawing ❑Any local requirements that are different from what is required on this form <br /> ❑ Other information(IIsQ:„ <br /> Upgrade Requlraments(denved from Minn. S(el.§115.55)An Imminent threat to)Public health and carted+(ITPHS)must be upgraded <br /> .repleecd,or ire use discontinued within len monilia of receipt'of this notice or wlthln a shorter period irrequired by kcal ondinence.Ir the system!s <br /> Farling to pmfecl ground water,the system must be upgraded ipploced,orris use discontinued within the time maulred by local ordinance. If in <br /> existing system is not falling as defiled in low,and has at least two feet of design so#separation,then the system need not be upgraded,repahed <br /> rap/aced,or Its use discontinued,notwilhstanding any kcal Ordnance that is mors 31111ek!This provision does not apply to systems in shorpland <br /> areas, Wi Ilhead Protection Amos,or those used in connection with food,beverage,and lodging establishments as defined in law. <br /> www.pca.state.rnn.us • -651-296-6300 800-657-3W TTY 651-282-5332 or 800-657-3864 • Available in alternative ro mats <br /> wq-wwists4-31 • 4124109 <br /> ' Prn1e'f of 8 <br />