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MINNESOTA POLLUTION <br />CONTROL AGENCY Compliance inspection report form <br />520 Lafayette Road North Existing Subsurface Sewage Treatment System (SSTS) <br />St. Paui, NIN 55155-4194 <br />Doc Type, Compliance and Enforcement <br />Instructions: Inspection results based on Minnesota Pollution Control Agency (MPCA) requirements and attached supporting <br />documentation — additional local requirements may also apply. Further information can be found here: <br />htt s://www, ca.st2te.mn-ur./sites/defau[Ufiiles/w-wwists4-31a. df. <br />Inspector must submit completed form to Local Governmental Unit (LGU) and system owner within 15 days of final <br />determination of compliance or noncompliance. <br />Property information Local tracking number: <br />Parcel 1D# or SecfTwp/Range: Local regulatory authority: J— J, e-0 <br />Property address: � 4qC) <-0 . <br />Owner/representative: Owner's phone: <br />Brief system description: - S1,"1 •( G•+ c e] rta 2i. K'y <br />System status ul,l,� A. eta c 66 by* <br />System status on date (mm/ddlyyyy):— } <br />Compliant— Certificate of compliance* ❑ Noncompliant — Notice of noncompliance <br />(Valid for 3 years from report date unless evidence of An imminent threat to public health and safety (ITPHS) must be <br />an imminent threat to public health or safety requiring upgraded, replaced, orits use discantinued within ten months of <br />removal and abatement under section 145A.04, receipt of this notice or within a shorter period if required by <br />subdivision 8 is discovered or a shorter time frame exists local ordinance or under section 145A.04 subdivision 8. <br />in Local Ordinance.) <br />*Note: Compliance indicates conformance with Minn. systems failing to protect ground water must be upgraded, <br />R. 7080.1500 as of system status date above and replaced, or use discontinued within the time required by local <br />does not guarantee future performance. 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 />❑ Tank integrity (Compliance component #2) — Failing to protect groundwater <br />❑ Other Compliance Conditions (Compliance component #3) — Imminent threat to public health and safety <br />Other Compliance Conditions (Compliance component 43) — Failing to protect groundwater <br />❑ System not abandoned according to Minn. R. 7080.2500 (Compliance component #3) — Failing to protect groundwater <br />❑ Soil separation (Compliance component #5) — Failing to protect groundwater <br />❑ Operating permiUmonitoring plan requirements (Compliance component #4) — Noncompliant- local ordinance applies <br />Comments or recommendations <br />Certification <br />l hereby certify that all the necessary information has been gathered to determine the compliance status of this system. No <br />detemunation of future system performance has been nor can be made due to unknown conditions during system construction, possible <br />abuse of the system, inadequate maintenance, or future water usage. <br />By typing my name below, 1 certify the above statements to be true and correct, to the best of my knowledge, and that this information <br />can be used for the purpose of processing this form. <br />Business name:--fjlsv } IJ.L , Certification number: �--OV 0 <br />Inspector signature: - - �( S License number: 3 °I q _ <br />(This document has been electronically signed) Phone: <br />Necessary or locally required supporting documentation (must be attached) <br />M Soil observation logs ❑ Locally required forms Tank Integrity Assessment <br />El operating Permit <br />FQ Otherinforma#ion (fist): <br />https://www.pca.stBte.mn.us 651-296-6300 800-657-3864 Use your preferred relay service Available in alternative formats <br />wq-wwists4-31b • 1/11/21 Page 1 of 4 <br />