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MINNESOTA POLLUTION <br />CONTROL AGENCY Compliance inspection report form <br />524 Lafayette Road North 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 form are located on the Minnesota Pollution <br />Control Agency (MPCA) website at https://www-pc2.state.mn.us/sites/default/files/wo-wwists4-31aodf. <br />Property information Local tracki I ng number: <br />Parcel ID# or Sec/Twp/Range: Reason for Inspection l <br />Local regulatory authority info: - $_)t7 <br />Property address; <br />Owner/representative: ���t, ��L- y� — Owner's phone:�i <br />—010 <br />Brief <br />Brief system description: 11L 6"Ic>vd�i S%�i1L��"si.lsl�� ) j ��Da1 X01 �ts4ri5 lL /� aic7 twCt,ass�7,j <br />t�>�Iz V rare # eTT" v�M NMS <br />System status <br />System status on date (mm/dd/yyyy): 3_t <1-a <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, subdivisfon 8 is discovered or <br />a shorter time frame exists in Local Ordinance.) <br />"Nate. 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 loco/ ordinance. <br />An imminent threat to public health and safety (ITPI-1S) 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 />❑ Other Compliance Conditions (Compliance component #3) - 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 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: (; - 9 ;l i �,A 11 , I, r.,,i ({ a Cert fti b <br />Inspector signature: <br />(This document has been electronically signed) <br />i sca son num er._,(,_ <br />License number:_ oy <br />Rhone:=t � , �4g_ r) . ?, <br />Necessary or focally required supporting documentation (must be attached) <br />9 Soil observation logs 31 System/As-Built ® Locally required forms .® Tank integrity Assessment <br />N Other information (list): c VM Q"" -A >4 617-%(94- <br />https://www.pca-state.mn.us 651-296-6300 800-657-3864 Use your preferred relay service <br />wq-wwists4-31b • 4/28/2421 <br />❑ Operating Permit <br />Available in alternative formats <br />Page 1 of 4 <br />