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MINNESOTA POLLUTION re Compliance inspection ort form <br />CONTROL AGENCY p p p <br />520 Lafayette Road North Existing Subsurface Sewage Treatment System (SSTS) <br />St. Paul, MN 55155-4194 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 />httos://www.pca.state.mn.us/sites/default/files/wq-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 trackina number: <br />Parcel ID# or Sec/Twp/Range: Local regulatory authority: tOo0 <br />Property address: <br />Owner/representative: �_V x} Owner's phone: 'I t,�5 ayS Mol �t <br />Brief system description: 'A c��l s rstL'1'Wn I <br />System status <-Or- A <br />System status on date (mm/dd/yyyy): 5 =J q --;L <br />) <br />Compliant — Certificate of compliance* <br />(Valid for 3 years from report date unless evidence of <br />an imminent threat to public health or safety requiring <br />removal and abatement under section 145A.04, <br />subdivision 8 is discovered or a shorter time frame exists <br />in Local Ordinance.) <br />*Note: Compliance indicates conformance with Minn. <br />R. 7080.1500 as of system status date above and <br />does not guarantee future performance. <br />❑ Noncompliant— Notice of noncompliance <br />An imminent threat to public health and safety (iTPHS) must be <br />upgraded, replaced, or its use discontinued within ten months of <br />receipt of this notice or within a shorter period if required by <br />local ordinance or undersection 145A.04 subdivision 8. <br />Systems failing to protect ground water must be upgraded, <br />replaced, or use discontinued within the time required by local <br />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 #3) — 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 permit/monitoring plan requirements (Compliance component #4) — Noncompliant - local ordinance applies <br />Comments or recommendations <br />Certification <br />I hereby certify that alt 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, possible <br />abuse of the system, inadequate maintenance, or future water usage. <br />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 <br />can be used for the purpose of processing this form. <br />Business name: r -,Q <br />" ��(iSiti�1�',/ t 1- L . Certification number: koaO <br />Inspector signature: � -- 'f�, 1r�c - RC 1 ✓4 \ A. License number: 3 °I %+ <br />(This document has been electronically signed) Phone: _ % (a3 - y c r2 ?, ��(1, to <br />Necessary or locally required supporting documentation (must be attached) <br />64 Soil observation logs ❑ Locally required forms Tank integrity Assessment ❑ Operating Permit <br />® Other information (list): 41,iW <br />https://www.pca.state.mn.us 651-296-6300 800-6S7-3864 Use your preferred relay service Available in alternative formats <br />wq-wwists4-31b • 1/11/21 Page 1 of <br />