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MINNESOTA POLLUTION Cpl-pMnnliainspection report form <br />CONTROL AGENCY N <br />520 Lafayette Road North Existing Subsurface Sewage Treatment System (SETS) <br />5t. Paul, MIS! 55155-4194 <br />Doc Type: Compliance and Enforcement <br />Instructions_ Inspector must submit completed form to Local Governmental Unit (LOU) and system owner within 15 days of <br />final determination of compliance or noncompliance. Instructions for filling out this form are located on the Minnesota Pollution <br />Control Agency (MPGA) website at htt s://www. ca.state.mn.us/sites/default/€iles/wg-wwists4-31a_.pdf. <br />Property information Local tracking number: <br />Parcel ld# or SeclTwp/Range: Reason for Inspection <br />Local regulatory authority info: <br />Property address:�,1�� u <br />Owner/representative: v j S 54ho%' re F�4 ,�) {�,�" 5 cA (M t C7 Owner's phone: (� j - a �$ • ��}-z. <br />Brief system description: a,.E'1OO tpk 5 ,'%i u -T'4), V- l 600 jai 9" w?' AyJ-t) f, aJt�k <br />Is uJi & to,A 50r s, OvT- 4 W-1-19PVVOt�� <br />System status <br />System status on date (mm/dd/yyyy): <br />® Compliant— Certificate of compliance* <br />(Valid for 3 years from report date unless evidence of an <br />imminent threat to public health or safety requiring removal and <br />abatement under section 145A. 04, subdivision 8 is discovered or <br />a shorter time frame exists in Local Ordinance.) <br />*Note: Compliance indicates conformance with Minn. <br />R_ 7080.1500 as of system status date above and does not <br />guarantee future performance. <br />❑ Noncompliant— Notice of noncompliance <br />Systems failing to protect ground water must be upgraded, replaced, or <br />use discontinued within the time required by local ordinance. <br />An imminent threat to public health and safety (1TPHS) must be <br />upgraded, replaced, or its use discontinued within ten months of receipt <br />of this notice or within a shorter period if required by local ordinance or <br />under section 145A. 04 subdivision 8. <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 />Ej 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 permit/monitoring plan requirements (Compliance component #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 determination of <br />future system performance has been icor can be made due to unknown conditions during system construction, possible abuse of the system, <br />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 can be <br />used for the purpose of processing this form. <br />Business name:S - °�� rj �l} 4 <br />LI���� _ _Certification number: , <br />Inspector signature: r <br />" License number: ;�fl; F: , _ <br />(This document has been electronically signed) Phone:`) t,,'� - L4. a �- 5"'A,. <br />Necessary or locally required supporting documentation (must be attached) <br />❑ Soil observation Ings ❑ SysternlAs-Built ❑ Locally required forms ❑ Tank Integrity Assessment ❑ Operating Permit <br />❑ Other information (list): <br />https://www.pca.state.mn.us 651-296-630o 800-657-3864 - <br />wq-wwist54-31b - 4/2812021 <br />Use your preferred relay service • Available in alternative formats <br />Page 1 of 4 <br />