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Minnesota Pollution <br /> iiro Control enc <br /> Compliance Inspection Form <br /> y Existing Subsurface Sewage Treatment Systems <br /> 520 Lafayette Road North <br /> St.Paul,MN 55155-4194 (SSTS) <br /> Doc Type:Compliance and Enforcement <br /> Instructions: Inspection results based on Minnesota Pollution Control Agency(MPCA) For local tracking purposes: <br /> requirements and attached forms—additional local requirements may also apply. <br /> RECEIVED <br /> Submit completed form to Local Unit of Government(LUG)and system owner <br /> within 15 days SEP 10 2014 <br /> System Status CITY OF ORONO <br /> System status on date(mm/dd/yyyy): <br /> ACompliant- Certificate of Compliance IDNoncompliant- Notice of Noncompliance <br /> (Valid for 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 /> 0 Impact on Public Health (Compliance Component #1)—Imminent threat to public health and safety <br /> El Other Compliance Conditions(Compliance Component#3)—Imminent threat to public health and safety <br /> ❑Tank Integrity(Compliance Component #2)—Failing to protect groundwater <br /> ❑Other Compliance Conditions(Compliance Component#3)—Failing to protect groundwater <br /> ❑Soil Separation(Compliance Component #4)—Failing to protect groundwater <br /> ❑ Operating permit/monitoring plan requirements(Compliance Component #5)—Noncompliant <br /> Property Information Parcel ID#or Sec/Twp/Range: <br /> Property address: /88? g/ c4 ', Reason for inspection: Seac <br /> Property owner: Owner's phone: <br /> or <br /> Owner's representative: Representative phone: <br /> Local regulatory authority: t�s / , �.1.1 ex 04,0 Re ulatory authority phone: <br /> Brief system description: 4/3 o,� <br /> Comments or recommendations: <br /> Certification <br /> I hereby certify that all the necessary information has been gathered to determine the compliance status of this system. No <br /> determination of future system performance has been nor can be made due to unknown conditions during system construction, <br /> possible abuse of the system, inadequate maintenance, or future water usage. <br /> Inspector name: d ex) z=.4.1 Certification number: 75"4 <br /> Business name: mi /4.4t 414 S /- rir c ��a.✓ Six.);re License number: „Zi <br /> Inspector signature: Phone number: 7 /-1 77 - /7,2 cc <br /> Necessary or Locally Required Attachments <br /> ❑Soil boring logs J System/As-built drawing ❑ Forms per local ordinance <br /> El Other information (list): ,% c.i 7 Ny// <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats <br /> wq-wwists4-31 • 1/24/12 Page 1 of 3 <br />