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MINNESOTA POLLUTION Com liance inspectionreport form H CONTROL AGENCY p 520 Lafayette Road North Existing Subsurface Sewage Treatment System (SSTS) St.Paul,MN 55155-4194 Doc Type:Compliance and Enforcement Instructions: Inspection results based on Minnesota Pollution Control Agency(MPCA) requirements and attached supporting documentation-additional local requirements may also apply. Further information can be found here: https://www.pca.state.mn.us/sites/default/files/wq-wwists4-31 a.pdf. Inspector must submit completed form to Local Governmental Unit(LGU)and system owner within 15 days of final determination of compliance or noncompliance. Property information Local tracking number: Parcel ID#or SecfTwp/Range: Local regulatory authority: 05(;) (0• - ytouo Property address: '.,O SSS t \_'4 0 -c?P,..• Owner/representative: '::1•tycr-dr4 Owner's phone:Q c - L) - Brief system description: )?,6 or\ pS.0C',!S 2. O ' ?�� ' 114-51-f, 4-- 6s.S v System status )0' �o swt c s,�=o <-uc- E s�;� System status on date (mm/dd/yyyy): (_i • { d - I El Compliant-Certificate of compliance ❑ Noncompliant-Notice of noncompliance (Valid for 3 years from report date unless evidence of An imminent threat to public health and safety(ITPHS)must be an imminent threat to public health or safety requiring upgraded, replaced, or its use discontinued within ten months of removal and abatement under section 145A.04, receipt of this notice or within a shorter period if required by subdivision 8 is discovered or a shorter time frame exists local ordinance or under section 145A.04 subdivision 8. in Local Ordinance.) Systems failing to protect ground water must be upgraded, *Note: Compliance indicates conformance with Minn. replaced, or use discontinued within the time required by local R. 7080.1500 as of system status date above and ordinance. does not guarantee future performance. Reason(s) for noncompliance (check all applicable) ❑ Impact on public health(Compliance component#1)-imminent threat to public health and safety ❑Tank integrity(Compliance component#2)-Failing to protect groundwater ❑ Other Compliance Conditions(Compliance component#3)-Imminent threat to public health and safety ❑Other Compliance Conditions(Compliance component#3)-Failing to protect groundwater ❑ System not abandoned according to Minn. R. 7080.2500(Compliance component#3)-Failing to protect groundwater ❑ Soil separation (Compliance component#5)-Failing to protect groundwater ❑ Operating permit/monitoring plan requirements(Compliance component#4)-Noncompliant-local ordinance applies Comments or recommendations Certification i hereby certify that all the necessary information has been gathered to determine the compliance status of this system. No determination of future system performance has been nor can be made due to unknown conditions during system construction,possible abuse of the system,inadequate maintenance, or future water usage. By typing my name below, I certify the above statements to be true and correct, to the best of my knowledge, and that this information can be used for the purpose of processing this form. Business name: S--'P 4 -<11Jt, 1)J (� , Certification number: ba') Inspector signature: -63, �� `.� cr( J (3. St,N� nS License number: 3 (This document has been electronically signed) Phone: 7 t Lk°1-r? 3 5�tn L' Necessary or locally required supporting documentation (must be attached) Li Soil observation logs ❑ Locally required forms la Tank Integrity Assessment ❑ Operating Permit E Other information (list): ?\...1q1.4 or w�I�� https://www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • Use your preferred relay service • Available in alternative formats wq-wwists4-31b • 1/11/21 Page 1 of 4