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05/08/2009 14:20 9528733112 PAGE 06/09 t . Minnesota Pollution Compliance Inspection Form Control Agency 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems (SSTS) St.Paul,MN SSISS-4194 Instructions on page 7. Parcel number: For Local Tracking Purposes System status: K/1 ompliant ❑ Noncompliant (based on aN ca ce requirements) Summary Form Property Information Property owner name(s): �.} Property address: Jctw Property owner's address(if di ferenty County: P iel owner phone: 9 - Pal - -----•••_•. [ �Pe Itting authority: Date system const ted: g Reason for Inspection: w System Description Brief system description: t` V\ ,/�� Local permit number; Number of bedrooms: Design flow rate:-_C Is the system: In Shoreland area? Ayes ❑No In Wellhead Protection Area? ❑Yes KNo An U.S. Environmental Protection System serving a Minnesota Department Agency (EPA) Class V Injection Well?❑ Yes 1%940 of Heath(MDH)licensed facility? ❑ YesNo 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 onel K— C ertificate of Compliance="valfd'until(3 years from date of report): Notice of Noncompliance For Noncompliant systems: The reason for noncompliance is: This noncompliant system Is classified as (check one below); ❑ Imminent threat to public health 8 safety ❑ Failing to protect ground water ❑Not in compliance with operating perm.: Certification (Completed form must be submitted to the local unit of government within 15 days,) I hereby certify that all the necessary information has been gathered to determine the compliance status of this sysrent ric determination of future system performance has been nor can be made due to unknown conditions during systern cortsrr:,ct,:r� possible abuse of the system,inedequIt fe mains nance, or future water usage, Name. _.=dsa �1]P� � Certification number: ----- a Business license name and number; Q_a, _ _ or Name of local unit of em _ Signature: Date: •-o.•/pp�� Gj - .....- Required Att ch•ments Inspector Complete:This Inspection Report is--��pages long, Check Comp a fors attached;&ydraulic Performance Tank Integrity Soil Separation ❑Operating Permit Form i,f applicable) rstem drawingfAs•built drawing ❑An assessmerfI of any local requirements that are different Ir what is requ rec on tris form ❑Soil Boring Logs ❑Abamonment form(if appropriate) ❑Other information(Ifkt); Upgrade Requirements(derived from Minn,Stat.6.115,55)An imminent Mreal to public health and safety rITPNS)must be upgraoso reoiacec its use discontinued wftn ten months of recoo orthis notice or wlrhtn a shoAer period If required by local oldlhance.if the systemic lading to orolecl;,roar.= water,the system must be upgraded,r+pfead,orits use discontinued wititin the time required by local ordinance,rf an exiso'ng system,s not larr.ng Is law,and has at least two Met of design sob separation,then the system need not bo upgraded,repeirad,replaced,or its use disconrrnued,nor,wrinva w.rq ig local ordinance that is more MCI. This provision does not apply to systems in shoreland areas,Wellhead Protection Areas,or those used n comp,! beverage,and lodging establishments as dellned in taw. ins sts4 31 et Compliance inspection Form for £xi9;irF SS'> l►nrt