2009 - MPCA compliance inspection form

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• Parcel number: System status: Compliant ❑Noncompliant (as determined y his form) Operating Permit Compliance and Nitrogen BMP Compliance Compliance Issue #4 of 4 Applicability: • Is the system operated under an Operating Permit? ❑Yes Zo If"yes",then complete item A, below Is the system required to employ a nitrogen BMP? ❑Yes No If"yes",then complete item B, If the answer to both questions is "no'; then this form does not need to be completed. below Compliance questions/criteria: (Required) (Check the appropriate box) A. For systems with operating permits: Has all the required monitoring and maintenance taken place and does the monitoring indicate compliance with the permit thresholds? ❑ Yes ❑No B. For a system that has a required nitrogen reducing BMP and does not have an operating permit: Is the nitrogen BMP in-place and appears to be properly operating? ❑Yes ❑No Any"no"answers indicates noncompliance Date of observation: V r? Reason for observation: V / /L - - Operating permit number: . This form expires upon next inspection or in three years, whichever occurs first: Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's (MPCA)Compliance Inspection Form for Existing Subsurface Sewage Treatment Systems. Observations, interpretations and conclusions must be completed by an advanced inspector, service provider, or maintainer(maintainer for holding tanks only). Completed form must be submitted to the local unit of government within 15 days. Property owner name(s): Property address: 9d0 s• iti Property owner's address (if different): County: Phone: I hereby certify that I personally made the observations, interpretations and conclusions reported on this form and that they are correct. Name: t/ Lit✓ Certification number: — -7 6 Business license name and number: or Name of local unit of government: • Signature: Date: q-wwists4-31 -w Compliance Inspection Form for Existing SSTS