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05/19/2011 20:56 7634975011 SPTESTINGINC PAGE 04/09' Minnesota Pollution compliance Inspection Form Control Agency Existing Subsurface Sewage Treatment Systems (SSTS) 520 Lafayette hood Norrll SL Paul,MN 55155.4194 Qoc Type.;Compli8nre and Fnforcenienl Instructions on page 7 §umllmary Form (Completed form must be submitted to the local unit of government within 15 days.) f6arcel number: _. -- "- For Local Tracking Purposes: Jyslem status: 0 Compliant ❑Noncompliant i (based an all compliance requiremen(s) Property Information Properly owner name(s): +M'GS �o,� 3>�ru• Property owner phone: 9.4u--ma-O g,lal ' Property address: aLJ 0 I Property owner address(Ii ditlerent): County: -OWL �•1 ' - Permitting authority: „1��( yTr Cz�t2�.►k�J Date system constructed: _�w�! 01 Reason For Inspection: Q�g .'( '�iq 5 _ tystem Description Brief system description: -1 s7 .1^`t1 �� Local permit number: r Number of bedrooms: _ _ Design flow rate: 7 Is the system: In Shoreland area? ❑Yes 0 No In Wellhead Protection Area? ❑Yes 9 No An U.S. Environmental Protection System serving a Minnesota Department Agency(EPA)Class v Injection Well?❑Yes M No or Heath(MDH)licensed facility? ❑Yes ®No Compliance Status (Based on stale requirements-additional local requiremerlis may also apply.) 1 Based on the infarmallon gathered and reported on attached forms, the compliance status of this system is(check one): a Certificate of Compliance-valid until (3 years from date of report): _ ❑ Notice of Noncompliance-For Noncompliant systems.- The ystems:The reason for noncompliance Is: _ This noncompliant system is classified as (check one below): ❑ Imminent threat to public health &safety ❑ Falling to protect ground water ❑ Not in compliance with operating permit certification ' I hereby certify that all the necessary information has been gathered to determine the compliance status of this system. No delermlhation of future system performance has been nor can be made due to unknown conditions during system construction, I possible abuse of the system,inadequate maihlenance, or future water usage. Name: �/��, L � '�'¢`� Certification number: l0 a el Business license name and number 1 ^Hg7�3$lalvor Name of local unit or government: Signature: C�' - Date: Required Attachments ® Hydraulic Performance Tank Integrity ❑ Operating Permit Form (if applicable) Soil Boring Logs Soil Separation System drawing/As-built drawing Any local requirements that are different from what is required on this form ❑Other Information(list): ypgrade Requirements (derived from Minn. Stat. § 415.55)An Imminent threat to public health and seloly(ITPHS)must be upgraded, placed,or Its use d►srontinued within ten months of receipt of this notice or within a shorter period if required by local ordinance.if the system Is i6iling to protect ground water,the system must be upgraded,reple cod,or Its use discontinued within the.time requlmd by local ordinance.If an 6xlsting system is not falling as dellned in law,and has at least Iwo feet of design soll separation,then the system need not be upgraded,repaired r6placed,or its use discontinued,notwithstanding any local ordinance that Is moreorict. This provision does not apply to systems In shorelend Areas, Wellhead Protection Argas,or those used in connection with food,beverage,And lodging establishments as defined in law. (rrww.pca.state.mn.us 651 196-6300 800.657.3564 TTY 651.261.5331 or BOD-657.3864 AVallable In attemative formats , _.._.:.._A 7. . AI4nIfM page i of 6