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• <br /> • <br /> Minnesota Pollution •Compliance .inspection Form <br /> - Control Agency Existing Subsurfa0e Sewage Treatment Systems <br /> 520 Lafayette Road North (SSTs) <br /> St.Paul,MN 55155-4194 <br /> Doc Type:Compliance and Enforcement <br /> Instructions: Inspection results based on Minnesota.Pollution Control Agency(MPONI <br /> For local tracking purposes: <br /> requirements and attached forms-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(mmldd/yyyy): °t= \1-1 4 <br /> 111 Compliant—Certificate of Compliance ❑Noncompliant-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 /> --r7t2b-a -Crtin,..wS �f-1\+ L«1 <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)-Imminentthreat to public health and safety <br /> ❑Tank integrity(Compliance Component#2)-Failing to protect gro ater <br /> O Other Compliance Conditions(Compliance Component 11`,3)-Falling to rotect groundwater <br /> ❑Soil Separation(Compliance Component#4) Falling to protect groundwater <br /> ❑Operating permitlmonitoring plan requirements(Compliance Component#5)-Noncompliant <br /> • <br /> Property information Parcel lQ#or Secrrwp/Renge:y-(�}.t,ta'11.1 6o - <br /> Property address: y S S U VJUI.V&ii-' R..41,e1 OW IsS.0 Reason for inspection: 64,a.-- ( '(¢A195c-1fl¢- <br /> Property owner: - Owner's phone: . <br /> or <br /> Owner's representative: 01.1-. 44r14"7, 4-, Representative phone: 1 t.3 -$‘44 `6u o', <br /> Local regulatory authority: G`-'S-< o lr D4.91-r-o Regulytory authority phone: °<Z,-Is;01,-1.;k,,00 <br /> Brief system description: a-ludo 424e,1 sc .ci_L,-(01-4.Y-S't I 27Ot,a1 4-C#r -fl LSoo>-K, ,wrcor • <br /> Comments or recommendations:14. Jo)/`Ss' 7-oz-v--'F7(09, 5`Z(6^' 'F` i4 47O T'‘ 1`i"O1^G <br /> Certification <br /> I hereby certify that all the necessary information has been gathered to determine be 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: �j f'e,v6.1 ,- GArNCI-- e\l'iQ'- . Certification number. (a.2,') <br /> Business name: 5 ��v4'r!�•''<11.1 1}S,n , License number: -` Ll- <br /> Inspector signature:i'....t7:-C-.6:4, Phone number. ?l03 -49.e)-"4,C.lv(o <br /> Necessary or Locally Required Attachments <br /> ®Soil boring logs System/As-built drawing 0 Formai local ordinance <br /> 0 Other information(list): d <br /> 1 <br /> WWW,P,Stdtt,mll,US ' 651-196-6300 • 800.657.3864 • TTY651.282'533Z or 800.657.3864 • Available In alternative formats <br /> wq•wwists4.31 . 1/24/12 i <br />