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jitinesota Pollution <br /> �. Control Agency Compliance Inspection Form <br /> ' 520 La0lette Road North E)&Aing SubswrIAGG Sew89e Tmetment Systems <br /> sx.P4u1,MN 55155-4194 (SSTS) <br /> Obs Type.Mance and Enftm ment <br /> Instructions: Inspection results based on Minnesota Pollution Control Agency(MPGA) For local traddng)hur�hoses: <br /> requirements and attached forms-additional kxxd requirements may also apply. a - <br /> Submit completed form to Local Untt of Government(LUG)and system owner <br /> within 16 days API? 2 <br /> System Status <br /> CITY OF ORONO <br /> system status on date(mmld ftM): y-1►}-� <br /> Compliant—Certificate of Compliance ❑Noncompliant-Notice of Noncompliance <br /> (Valid for 3 years firm repod date,unless shorter time (See upgrade Requirements on page S) <br /> frame outlned In Local Ordinance.) <br /> Reason(s)for noncompliance(check a#eMicioe) <br /> ❑Impact on Public Health(Compliance Component #t)-Imminent threat to pubft health and safety <br /> ❑Other Compliance Conditions(Cqunptlarm Camponsnt#3)-1 mminent threat to public health and safety <br /> ❑Tank integrity(Compliance Component #2)-Falling to proter#groundwater <br /> ❑Other Compliance Conditions(Compllame CoMponant#3)—Faging to protect grnundmt+er <br /> 0 Soll Separation(Compliance Component #4)-Fallhmg to protest MwndHrater <br /> ❑Operating pernMimonitoring plan requirements(Cornpl/ancs Component #t)-Nwcomptant <br /> Property Information Parcel IN or seaftplRange: = S_og,Q <br /> Property address: 131t2 �ti! �9u3�s.1_-0W`040440 Room for Inspection: <br /> Property owner owner's phone: <br /> or <br /> Owner's representative: Representative phone: <br /> Local regulatory authority: Regulatory authority phone: 9 4- -avt9 -4c;ov <br /> Brief system description: a j 4,.m v"-,7-44)4 V--�( y,r;, <br /> Comments or recommendations: 14 !nm <br /> Certification <br /> 1 hereby certify that all the necessary lnfbrmagm has been gathered to MWMbw the co MM&t ce status of this system.AAD <br /> determination of future system peftanance has beer+nor can be Mede due to ta*WM con Wons during system oa nstntctlon, <br /> possible.abuas of the system,inadequate maintenance,or Ad"water usage. <br /> inspector name: tom. Certtflsatian number G,. ,0 <br /> Business name: �( Uoome number: _ Iq�tl <br /> Inspector signature: - <br /> Phone number: '�1ia:� t.�q _•r,c,L <br /> Necessary or Locally Required Attachments ._ <br /> IS Sop boring logs ®System/As-bulk drawing [)Forms per loom ordinance <br /> ❑Other information(list): <br /> WWYt►pca stacc.mn, 45t-296.6300 �a657.38Ni TrY'01-M-5331 or 800.65'13864 • AraRable ti Tutt tliattM formats <br /> wTww1s&4-31 • 1/24112 <br />