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MINNESOTA POLLUTION <br />CONTROL AGENCY Compliance inspection report farm <br />_ <br />520 Lafayette Road worth Existing Subsurface Sewage Treatment System (SSTS) <br />St. Paul, MN 55155-4194 <br />Doc Type. Compliance and Enforcement <br />Instructions: Inspector must submit completed form to Local Governmental Unit (LGU) and system owner within 15 days of <br />final determination of compliance or noncompliance. Instructions for filling out this forth are located on the Minnesota Pollution <br />Control Agency (MPCA) website at https://www.12ca.state.mn.us/sites/default/files/wo-wwists4-31a_.pdf. <br />Property information Local tracking number: <br />Parcel ID# or SecfTwp/Range: Reason for Inspection a <br />Local regulatory authority info: G <br />Property address: <br />Own erfrepresentative: Owner's phone: 1. 4 c) -L4 19 <3 a, <br />Brief system description: 1 100 t�1 -tyT r 130U M? � � j 1) .1,0 5.1 ..V%w -+r 11oul,1 rrum i? <br />Il ra A j 4�i "005UJB-Cly IR Jo' Y iso 1 TV t,* <br />System status <br />System status on date (mmfdd/yyyy): <br />W' 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. 7080.9500 as of system status date above and does not <br />guarantee future performance. <br />❑ Noncompliant — Notice of noncompliance <br />Systems fatting 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 (ITPWS) most 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 loval 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 />❑ Other Compliance Conditions (Compliance component #3) — Falling 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) — Falling 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 nor 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, t 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: <br />Inspector signature: <br />3(7" <br />w r t� A , ___•... �- f" <br />3 (this document has been electronically signed) <br />CerHcation number: {� , <br />License number: 129 <br />Phone: '2, -t.t <br />Necessary or locally required supporting documentation (must be attached) <br />❑ Soil observation logs ❑ System/As-Built ❑ Locally required forms ❑ Tank Integrity Assessment M Operating Permit <br />❑ Other information (list).- <br />https://www.pea-state.mn.us 651-296-6300 800-657-3864 Use your preferred relay service Avai{able in alternative formats <br />wq-wwists4-31b • 4/28/2021 Page 1 of 4 <br />