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z Minnesota Pollution Control Agency Compliance Inspection Form ti 520 Lafayette Road North Subsurface Sewage Treatment Systems (SSTS) St. Paul, MN 55155-4194 Doc Type: Compliance and Enforcement Inspection results based on Minnesota Pollution Control Agency (MPCA) For local tracking purposes: requirements and attached forms — additional local requirements may also apply. New System System Status System status on date (mm/dd/yyyy): 12/14/2018 ® Compliant — Certificate of Compliance (Valid for S years from report date, unless shorter time frame outlined in Local Ordinance.) Reason(s) for noncompliance (check all applicable) ❑ Noncompliant — Notice of Noncompliance (See Upgrade Requirements on page 3.) ❑ Impact on Public Health (Compliance Component #1) — Imminent threat to public health and safety ❑ Other Compliance Conditions (Compliance Component #3) — Imminent threat to public health and safety ❑ Tank Integrity (Compliance Component #2) — Failing to protect groundwater ❑ Other Compliance Conditions (Compliance Component #3) — Failing to protect groundwater ❑ Soil Separation (Compliance Component #4) — Failing to protect groundwater ❑ Operating permit/monitoring plan requirements (Compliance Component #5) — Noncompliant Property Information Parcel ID# or Sec/Twp/Range: Property address: 1140 Wyndmere Road Reason for inspection: New System Property owner: Owner's phone: or Owner's representative: Local regulatory authority: Metro General Service Inc. of Orono Brief system description: Type I Mound Comments or recommendations: Mound Repair Certification Representative phone: 763-428-2938 Regulatory authority phone: 952-249-4600 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. Inspector name: Roger Peitso Business name: Olt r Inspector signature: Necessary or Locally Required Attachments M Soil boring logs ❑ Other information (list): ® System/As-built drawing Certification number: #6683 License number: Phone number: 952-249-4625 ❑ Forms per local ordinance www.pca.state.mn.us 651-296-6300 800-657-3864 TTY 651-282-5332 or 800-657-3864 • Available in alternative formats wq-wwists4-31b • 614114 Page 1 of 3