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. . � -�; ��t�,nesota Po�!ut�on � Comptia ce lnspectio.n �orm <br /> Con�'ol Agency Exlsting Subsu �e Sewage Traatment Systems <br /> � 520 Labyette Road North (SSTS) <br /> 5�.P7u1,MN 55155-4194 - <br /> Doc 7ype:ComW/ence and Erttorcement <br /> InstrucUons: Inspection reaults based on Minnesota Poliution Contrd Agency{MP ) For bcel trecking purposes: <br /> requicamerns and attached tortns—additional local requiremer�ts may also apply. <br /> Submlt compietsd form to Loca!Unit of Oovemment(LUG)and aystem o <br /> within 15 days <br /> System Status <br /> Syatem atatua on date(mmlddlyyyy): ��T�—1�3 <br /> �Compllant—Certlficate of Compliance ❑Non ompitant-Notice of Noncompliance <br /> (Valid for 3 years from tvpat dete,unless shorter tlme {See pglade Requlremenis on page 3) <br /> fiame outllned in tocal Ordlnance.) . <br /> Reason{s►for noncompilance(check all appllcable) ' <br /> ❑Impact on Public Health(Compliance Component#i)-Imminenf ih at fo pu6Uc health and safety<- <br /> ❑Oiher Compliance CondWons(CompiFance Component�13J-Immirte t thraat fo pu61k heaJfh and safety <br /> ❑Tank integrity(Comp!larrce Componenf#2)—FaHing to proted grou ter <br /> ❑OtherCompliance Conditfons(Compl/arrce Componenf�3)—Falling protectgraundwater <br /> ❑Soil SepacaUon(Compllence Companent#4j—Felling to profect gro water <br /> ❑Operating permiUmonitoring plan requirementa(Compllance Compo t�5)—Noncompliant <br /> Property Information ParoeilD#orSeclT ar►9e: •.�1�.s.��r.n,s..a , <br /> Property address: �3 tot7 ��1�S�orG'CZ�.' r'P-c9 f.�o R n for inspedion:�¢oY���f4^A'�_5'�c� ,. <br /> Property owner. ��w� U�.S O�l era phone: (,F2- 51 i3-H 4 1 b'. <br /> or - , � , <br /> Owners reprosentative: � ' '� R entative phone: � • <br /> Locei repulatory auihority: �:��(� o G r�y-c9 f�o R uletory authwity phone: 9'S a,-��l`1-y�,00 <br /> erief system descAption: = uc>c� 4� Sd�s� c � � <br /> Comments or recommenda8ons: r..�ti��rrr.+� i,o>�c'So' ¢o�'f'�� 5� '� '�'�•'a' '-{�''�"'�°n"'"' �ad""�t. <br /> , . • � ' <br /> Certificat9on <br /> !hereby certify that all the ne�ssary Infomra5on has besn gafheied to determin the CompUaAce status of this sysfem.No <br /> detertninetfon of luture aystem performance has beeh nor can be made due to u caid►t/ons during system conshucdort, <br /> poss7ble.a6use of dre system,lnadequate maimenanca,or fidurg water usaqe. <br /> �nspector n�ne: S�f�Gv�'�_+�j.-SGN14rt�G�� Ce n number: �,7 <br /> Busineas name: -� � LlCense nUmber. ��i.�- <br /> Inspedorsignature: �� ,� ' Phonenumber. �1(o'S �4q.�}—?,Sl,(o <br /> Necessary nr Locally Required Attachments <br /> �Sai boring logs �System/As-buftt draMring ❑F per local ordinance <br /> ❑Other information(Ifat): � <br /> WWVt,pCa,StdiE.fftll�US • G51•246•6300 � S00•657•3564 � iT'(691•2d2• 32 or 800-657•3864 � Ava�table tn altematNe tormau <br /> wq•wwfs[s/•31 • f/24/1I ` . <br />