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Minnesota Pollution Compliance Inspection Form u ► Control Agency 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems (SSTS ) St.Paul,MN 55155-4194 Instructions on page 7 Parcel number: For Local Tracking Purposes: System status: ❑Compliant ®Noncompliant (based on all compliance requirements) Summary Form Property Information Property owner name(s): '(Z Property address: 5so Property owner's address(if different): County: N G�.1�J'�/41�.5 Property owner phone: Permitting authority: _G��'�i 0-q� Date system constructed: i Cl Reason for nspection: $LSA System Description Brief system description: p S N Local permit number: Number o bedrooms: _ Design flow rate: Is the system: In Shoreland area? ®Yes ❑ No In Wellhead Protection Area? ❑Yes ® No An U.S. Environmental Protection System serving a Minnesota Department Agency(EPA) Class V Injection Well?❑Yes ® No of Heath(MDH)licensed facility? ❑Yes a No Compliance Status(Based on state requirements—addi ional local requirements may also apply.) Based on the information gathered and reported on attached forms,the compliance status of this system is(check one): ❑Certificate of Compliance—valid until (3 years from date f report): Notice of Noncompliance-For Noncompliant systems: The reason for noncompliance is: This noncompliant system is classified as(check one below): ❑ Imminent threat to public health&safety ®Fail!nC to protect ground water ❑ Not in compliance with operating permit Certification (Completed form must be submitted to the to I unit of government within 15 days.) I hereby certify that all the necessary information has been g 3thered to determine the compliance status of this system. No determination of future system performance has been nor ca i be made due to unknown conditions during system construction, possible abuse of the system,inadequate maintenance, or ft tune water usage. Name: S Certification number: 0 Business license name and number: rj —Q -"- r or Name of local unit of government: Signature: Date: Required Attachments Inspector Complete:This Inspection Report is pages long. Check compliance forms attached: ®Hydraulic Performance ❑Tank Integrity ®Soil Separation ❑Operating Permit Form(if applicable) IN System drawing/As-built drawing ❑An assessment of any local requirements that are different from what is required on this form IS Soil Boring Logs ❑Abandonment form(if appropriate) ❑Other information(list):"4rw Upgrade Requirements(derived from Minn.Stat.§115.55) n imminent threat to public health and safety(ITPHS)must be upgraded,replaced,or Its use discontinued within ten months of receipt of this notice or within a porter period if required by local ordinance.If the system is failing to protect ground water,the system must be upgraded,replaced,or its use discontinued wil hin the time required by local ordinance.If an existing system is not failing as defined in law,and has at least two feet of design soil separation,then the system n ed not be upgraded,repaired,replaced,or Its use discontinued,notwithstanding any local ordinance that is more strict.This provision does not apply to systen s in shoreland areas,Wellhead Protection Areas,or those used in connection with food, beverage,and lodging establishments as defined in law. wq-wwists4-31 Compliance Inspection Form for Existing SSTS 411108