Laserfiche WebLink
, MINNESOTA POLLUTION Cprp liance <br />CONTROL AGENCY p inspection report form <br />520 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 htt s://www. ea.state.mn.us/sites/default/files/w-wwists4-31a. df. <br />Property information Local tracking number: <br />Parcel ID# or Sec[Twp/Range: reason for Inspection <br />Local regulatory authority info: L.®%,o N-& �2 <br />Property address: ,-A , t <br />Owner/representative: cc.60- 5qt�Y4— Owner's phone: Ot- Rgtp- 0116A . <br />Brief system description: <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 />Ll [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 (ITAI-IS) 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, 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. '- <br />Inspector <br />Inspector signature: <br />(This document has been electronically signed) <br />Certification number: a") <br />License number: 3 �) 4 <br />Necessary or locally required supporting documentation (must be attached) <br />❑ Soil observation logs ❑ System/Aa-Built ❑ Locally required forms ❑ TanK Integrity Assessment ❑ Operating Permit <br />❑ Other information (list): <br />https://www.pca.state.rnn,us 651-296-6300 800-657-3864 <br />wq-wwi5ts4-31b • 412812021 <br />Use your preferred relay service Available in alternative formats <br />Page 3 of 4 <br />