Laserfiche WebLink
. r - T��,nesotaPa��ut�on ��Compliance fnspectio.n F`orm <br /> Control Agenty Extsting Subsurface Sewage Treahn�nt Sy�t�ms <br /> ` S1oLafayetteRoadlVarth �S�$� <br /> 54P�ui,MN 55155-4194 <br /> � Doo 7YPe��+►iP�armlEnfmr�rtant <br /> inatructio�: Ins�eCtton re�lts based on M1l�nnesote•PoAutlon ConVol Ager�.y(MPC•A} For Iocal tracking purPcses: <br /> r�y���i attac�a fnrn,s-�amor►�a toc�re�U�nent��Y���Pv�r• f��Po t� <br /> Submit aompleted form to Loc�1[init ot(iovemment(LUO�and sYstam owi►sr ` � <br /> within 15 ttays . <br /> . b � �"^ <br /> . r <br /> System Status <br /> Sysfam stetws on dete(mmlddiYYYY}: � �a� ^1�-1 . . <br /> ❑Compllant—Certificate cf ComPliance �Noncomgliar�t--Wotice of Noncompliance <br /> �frame��In Locaf O�i�eartce.�less�rarterNme (See Upgtade Requlrsma�an P898 3) <br /> Reason(s�tor nvncon�p�lance(check ali eppllcable) ` <br /> ❑Impacct on Pt�lic HeaHh(Compaa►►ce CanPonent#i)`(mm�enttmeetbpubQchealth and se%ly. <br /> ❑dtt►er Campliaaee CondiHona(Compltarrce Compatent�3)-lmmtnert!tl�reaf to pubNo heal�h end safety <br /> �Tank kste8rity(Cam�arx�ComPaner�t�2)-FaBh'g to p"�ed g�°ir'�rM`ater • <br /> C7 other Compiian�Cond�ians fComAAe�rce CmnPonent�k9?-FaRUrg to p�ect gr�dwaier <br /> �SoU SsparaUan{Compner►oe CompartBnt#4}�FalUn9 to prrtteat gmundwatsr ' <br /> ❑Operatln9 Permif/monit�n8 P��lulremerts{�CanPuner�+�67-Noncompltant <br /> Property information t�arce�t�or s�n9e: '��-ir� `� � <br /> P�operty address: �l a�►0 14�,r-u.�oo�.S•:Ai A�l va.9��vR�ior mspedton:����-CS�s�' <br /> proPedY oWner: `!S'��P`� F'�, t41Pt��is:� Owners phone: '� <br /> or . � <br /> �wnersrepresantaitve: �4�1v►.�bg����.�eF� Representellvephone: t�a_-•+��o� t�35a <br /> Localre9��euthnrilYs _l�S"� rr�_, ��rJ.o • ,• RegulstoryrautharllYPhone: q5�.-a�9 -�1.bon <br /> BdefayatamdescrtpNon: a=�auo�t �l�rv� �av 3.f��.►,a.�t o*r�4-�tsua. 6��1 n 4 saXr�. '_._„_. <br /> CwnmeMs or recommendaticns: ,. , • , , . � � � . . <br /> � . . , . , . . . . <br /> CerNfltation <br /> 1 haraby�thef aA the aecessary Irtforme�en has heen gathered to detemi6re the G�mpllat�ce status of thls system.�No <br /> detam�lnnaHcn of fi�ture sy�em perfio►mence hes beeh narcan be tnade due to w�oxm ca�drdons dudr►g aystem coa�lon� <br /> posslble abusa otlhe ayste»L inadequate meGGtter+ance,or flRwe wa[er r�ge. <br /> inspedornama� �S�'IJi•G..� ,/1j��,L`ut4.re�� CerHflcadonnumber. •fr�.�3..'I - <br /> Bustrressr�ame: 5�4 �+� � �k��� — l.lce�anumber. �ci�- <br /> Inspector signeture� r. �-- Phorre number. �tn?, ��.�!-��lDto <br /> Nece"ssary or Localty Required Attathments <br /> �Sof{bodng Eogs �SystertVAs-b�illt drawl� (a Forms per local ordtnenc� <br /> ❑Other fifam�aticn(�st): _ � <br /> vNPM,�a,StBte.mn.u3 • b51-Z7�6300 • 800�657•3864 • 1'iT�651•28Z•5332 cr 8U0�657-3844 � AvaRable in attematNe fmma� <br /> peq ww1sK4-31 • f/I4f 12 � ' � <br />