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Oct. 31. 2013 12: 03PM No. 2113 P. 5 <br /> • <br /> • Minnesota Pollution Compliance Inspection Form <br /> i4�;f n•;,r9a`a�; <br /> Control Agency <br /> 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems <br /> SL Poul,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 /> 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): 1 0 - <br /> 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 /> 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 /> LI Tank Integrity(Compliance Component #2)-Failing to protect groundwater <br /> 0 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 Secrrwp/Range: <br /> Property address: x0147LI,J o t3'c i4\, C O 7>a Reason for inspection: �gy sy <br /> Property owner: d�i1\ (�Z� Owner's phone: q 5 a- ')oil 4 <br /> or <br /> Owner's representative: _ Representative phone: <br /> Local regulatory authority: LA'{,•c o (71.4Q Regulatory authority phone: g 5 -I%-y21 4 <br /> Brief system description: l'A.50 r��v,,y,l 5 � -(i s��t }I a So ,l awwk at?,1'' .41.4 tAk. a f Y wv1 <br /> Comments or recommendations: ,a,,ak,„ i.u, -C 4 5`d sc2,4-c Foy* <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: .- Certification number: _Lai_ <br /> ') <br /> Business name: License number: 3°i.Li- <br /> Inspector <br /> +Inspector signature: 0)2 Phone number: ')Ldp f 4 1 - 5 L,(A <br /> Necessary or Locally Required Attachments <br /> 2 Soil boring logs ®System/As-built drawing 0 Forms per local ordinance <br /> ❑Other information(list): <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 <br />