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• <br /> ivfPtlnesota Pollution core • <br /> Control Agency prance Inspection Form <br /> 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems <br /> St.Pqut,MN 55155-4194 (SSTs) <br /> Doc Type:Compliance and Enforcement <br /> Instructions: Inspection results based on Minnesota Pollution Control Agency(MPGA) For local tracking purposes: <br /> requirements and attached forma-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(mmlddlyyyy): 9 3- l 9 <br /> 0 Compliant—Certificate of Compliance "Pi Noncompliant-Notice of Noncompliance <br /> (Valid fir 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 #1)-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)-Falling to protect groundwater <br /> ®Other Compliance Conditions(Compliance Component#3)-Failing to protect groundwater <br /> • <br /> ❑Soil Separation(Compliance Component #4)-Failing to protect groundwater <br /> ❑Operating permit/monitoring plan requirements(Compliance Component #5)-Noncompliant <br /> • <br /> Property Information Parcel ID#or S <br /> ec/Tvrp/Range: l-}044.5 ►�,. <br /> Property address: pa -4t)<e;, <br /> Reason for inspection: .?1,,)Q(0rr�-{ <br /> Property owner. Q6/-1 q.0 _'-? . Owner's phone: b1 a_ - rr 3.3 Lo <br /> or <br /> Owner's representative: Representative phone: <br /> Local regulatory authority: .c". ©. ,.-)J Regulatory authority phone: 9 5 a -d49 - 4eo0 <br /> Brief system description: a-1 at,o d� ski -WY(.- 1-a 4 .1�n:7 <br /> Comments or recommendations: vJ\4N C i o' ,t 5 l' V'� s 1 4,) P��, A. .fi g'cnK u ov.sv. ���� �� <br /> Certification <br /> !hereby certify that all the necessary information has been gathered to determine the compliance status of this system.No <br /> determination of futum system performance has been nor can be made due to unknown conditions during system construction, <br /> possible abuse of the system,inadequate maintenance,or futum water usage. <br /> inspector name: 5--1".01,6.1 ,i!2),.Sati -c-.. Certification number. <br /> Business name: " 4 E� •31::1, <br /> (v, <br /> - License number. 3c,l_ <br /> Inspector signature: ,, • f , ,--- -- Phone number: '7 <br /> Necessary or Locally Required Attachments <br /> Soil boring logs ®System/As-built drawing ❑Forms per local ordinance <br /> ❑Other information (list): <br /> vnicpca,state,mn.us • 651-296-6300 • 800-657-3864 • TTY651.282.5332 or 800-657-3864 • Available in alternative formats <br /> wq-wwists4-31 • 1/24/12 <br />