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MINNESOTA POLLUTION CONTROL AGENCY Compliance p <br />ance ins action report form <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 (MPGA) requirements and attached supporting <br />documentation - additional local requirements may also apply. Further information can be found here: <br />https://www.l)ca.state.mn.us/sites/default/fileslwci-wwists4-31 aadf. <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 ID# or SecTFwp/Range: Local regulatory authority: Lo \4 U% y-,� 0 h, 9 wo <br />Property address: <br />Owner/representative: uOwner's phone: <br />Brief system description: �000 1?Z0 <br />System status 4- 1-a s© s�t�t ^- s 4 u� ��k�o� W 41514 54�4;p SAGV_ Lo ) <br />System status on date (mm/ddlyyyy): b -0. "A 1 <br />W 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. 7080.9500 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, orits use discontinued within ton months of <br />receipt of this notice or within a shorter period if required by <br />local ordinance or under section 145A.04 subdivision B. <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) - ,wiling to protect groundwater <br />❑ Soil separation (Compliance component #5) - Failing to protect groundwater <br />❑ Operating permit/monitoring plan requirements (Compliance component #I~4) - Noncompliant - local ordinance applies <br />Comments or recommendations <br />Certification <br />I hereby certify that all 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 />Ey 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: 5--' Ii�3 , I 1 L , Certification number: <br />Inspector signature: "!� '0, License number: Z '14 <br />(This document has been electronically signed) 'Phone; L, 5, <br />Necessary or locally required supporting documentation (mast be attached) <br />W Soil observation logs ❑ Locally required forms Tank Integrity Assessment ❑ Operating Permit <br />114 Other information (list): <br />https;f jwww,pca,state,mn,us 651-296-6300 800-657-3864 Use your preferred relay service s Available in alternative formats <br />wq-wwists4-31b • 1/11/21 Page 1 of 4 <br />