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Control Ag Pollution Compliance Inspection Form <br />Control Agency {� <br />520 Lafayette Road North - Existing Subsurface Sewage Treatment Systems <br />Wint,MN55155-4194 <br />(SSTs) <br />Doc Type: Cotnoance and Enromoment <br />Instructions: Inspection results based on Minnesota Pollution Conhol Agency (MPGA) For local tracking purposes: <br />requirements and attached forms - additional local requirements may oleo appy. <br />Submit completed form to Local Unit of Govemment (LUG) and system owner <br />within 15 days <br />System Status <br />aystam status on date (mmlddlyyry): _ 0-30-j-) <br />❑ Compliant- Certificate of Compliance Noncompliant - Notice of Noncompliance <br />(Valid for 3 years from report date, unless shorter time <br />Imme outlined in Local Ordnence.) (Sea Upgrade Requirements on page 3) <br />Reason(s) for noncompliance (check all applicab/al <br />0 Impact on Public Health (Compliance Component #f) _imminent threat toPubli, health and safety <br />❑ Other Compliance Conditions (Compliance Component#3)-/mminent throat to public health and safety <br />❑ Tank Integrity (Comp#arae Component #2) _ Failing M protectgmuntl threat <br />❑ Other Compliance Conditions (CompOence Component#3)- Failing to Protect groundwater <br />® Soil Separation (Compliance Component #4)- Paling loprotect groundwetar <br />❑ Operating parms/moniWdng plan requirements (Compliance Component #5) - Abncampllant <br />Property Information <br />Property adtlresa: Wy$ <br />Parcel lD# or SediWp/Range: <br />_A� 9�J ye <br />Props owner. Reason for Inspection:k ,(QgiSSFC�y <br />nYet7} $t�-�i.Q.,�1p. <br />or Ow—Mer sphone: bl'a-QacQao-93 <br />Owners representative: <br />Local regulatory authority:G RePrsesntdn phone: <br />_I-C� drr H•P 4�1,� RepWetoryallftrib Wane: aSa-ay9 -4teo0 <br />Brief system descriptio: na SroF•(tL -C rkS1y Atyo l <br />Comments or recommendations: �..t2S 1-01-'" �a'd��'�` 3S0 1. � I OSO Sgt:( <br />Certification <br />1 hereby cert fy 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, <br />Possible abuse of the system, Inadequate maintenance, or future eater usage. <br />Inspectorname: S-{{�jy(iy ,1S .SG�1R-M -Y✓ <br />Business name:.( n Certification number. <br />Inspector signature: w..� License number. sq,µ <br />-- fz `-'— Phonenumber. 7tn:S—�gn_i, qL„t <br />Necessary or Locally Required Attachments <br />® Soil boring logs ® System/AS-built drawing ❑ Forms per local ordinance <br />❑ Other information (tial): <br />%gw,WI6t54ate.mn.lM112 651.29G63gti at1P657.3564 'IT 07.252.5332 or M657-3884 • Available in altemadve formats <br />agwwlats4-3f f134/f7 <br />