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, ' - �tl�fftnesota Paliution �.C�mp��$nCe' 1�'1SpeCt�O.I'1 �Orl"Cl <br /> Control Agency �j�SubsurEa+�Sevv��Tre�tment Systems <br /> ' S10 LafaYette Raad Narth tg�g3 <br /> 54?Aul,MN S57S5-4194 �,�;������ <br /> lnafiuctlons: Insl��o���b�ed on Nirute�te.Po9uuti�or►Cot�Cl A9�Y(�P�? For Iocal 1[ackln9 P�� <br /> �s�d attet�ed forma-addtilone�toc���Y��Y <br /> Submit aomplsted totat to l.ot�i ilntt o�Oo�remme�(LU4�and eyst�m ovr�►9r <br /> witltitt 1B�s . <br /> System Status <br /> gyste�n statue on dabe tmmlddJY9YY}: ���i� ^1�-1 . . <br /> ❑Compllant-Certtfic.�of Compliance �P�Oncompliant-Notice of Noncompifance <br /> (Vadd tar 3 years hrnn re�rt date,+!►��shorterE�e fSee UAB��Req�dt�ne�on page 31 <br /> trame ouGtU�ed JR t�l ordt�arrce.J . <br /> Fts�on(s)for nancompltance(cheak all epP►tcable) � <br /> ❑Impact an Pt�►I�Health fCamFUa►u:e ComFonertt�!)-Ir�nfnent Nuueaf b pubdc hee�f►end�feqF. <br /> Q Other ComP��n�tona fComplfance ComP?���3)-�mminertt fhreat Go pr��e heafbt and safety <br /> ❑Tank ttzte�tty(C�mp�ar��ne��1"�8 m P�9�+��er . <br /> D�er Comp�ant�Cand�ons(Cn�Ccmparent�l-F�r�to a►a�� <br /> �Sa@ S+aP����anca Cor►+Porrant it41'-�to P�A�o+mBwater . <br /> ❑Ope�atlng A�►tt/monllutin8 P�I+�W�temet�ts{�e CamPor►e��-Na►r.on+i�ftaM' <br /> Rroperty infocmatlon r��m�a se�m,p�s& 3�'� '� � <br /> property addtess: �y,a�►o t�h�,F-w ov,.�•u��wt�2r ¢�,,SvR�t tar inspedi�:�p,�.d,� _ -�'P�s�Z: <br /> pro�edY�vner: "r'�� F������ _.. Owner's phone: '-' - <br /> 0� . <br /> Qwner'arepresenkaUve: -faoMbss;�+..L�� Representegvepho�te: t�*�_-�+.��a� to35� <br /> Leaat re9��Y autho�y: -s.Y�"� rr� d4�s�0 � • ReQulatorY authorlly Rhone: g 52.-oly9 -�boq <br /> @rlet aystem descRpt6on: _�'two s •(�►s-v,c.. tksac 3 �-+r.��C.4�'(P.6a.so,s. 6��f1o.n ��p sa�. -- <br /> Canmer�ts or r�ecommendatlnns: ,• , • , � . � � . . <br /> � . , , . , . . , . <br /> �@TE�flC8t1QA <br /> 1 he►ebY ce►tJN thef aH the aecesaerY��►has t�en ga�t►a�ed to dedemi6re#re aotnp�ce status of this sysfem.Afo <br /> delem�naHon of fulure system Pertormara�1�s been r�arcen be made due to ru�vmwr+ca�aHBona dudrrg sY�em ao►rstruatlon, <br /> poasible abuse of dre aY�enr.irtade4uedQ�.or fuhns waterusage. <br /> �.G..� ,R� .SG1-1ti�-�!;�'�.� Certlftcatlon number. .a.�_ <br /> Inspe�Acr nama: ��..�,,�_� <br /> Businesa na�: S�' -C �����kL�, U�nwnber. 3��- . <br /> Inspsctor s��t�re' ,�^.' . .,.�- Phone number. �Jt..� -�+.LAr�}-�,'SlnSo <br /> Necessary ar Localty Requ�red Attathments <br /> �8al{boring fogs ■BYstemfAs'b�t dtawing G7 Fames per Ioce1 ordtnanc� <br /> ❑Otlter ir►fom�ffiion{�s�. . <br /> Y�NPN,pCa.5t8[e,m�t.t� • 66t•�fr6300 • ��7•3864 • 'FtY�G51282•5332 ar�D�657•�44 • AvaQable�n attematfre tormats <br /> . ` <br /> wq.wwlsts4�31 • ?lxAl t2 d � <br />