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MINNESOTA <br />CONTROL ,&GENCY POLLUTION Compliance inspection report p t fo rm <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 (MPGA) website at htt s:J/www. ca.state.mn.usJsites/defaultl€files/w-wwisfs4-31a. pdf. <br />Property information <br />Parcel ID# or 5ec/Twp/flange: <br />Local regulatory authority info: <br />Property address: g 010 <br />Local tracking number: <br />Reason for Inspection ,f f <br />Owner/representative: <br />Brief system description: GO L) 1 ,1 �Ft,,4ra <br />System status <br />System status on date (mm/dd/yyyy): 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 1455.04, 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 />Owner's phone:,, <br />El Noncompliant – Notice of noncompliance <br />Systems failing to protect ground water must he 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 a. <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 acrd safety <br />ElOther 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 45) – Failing to protect groundwater <br />❑ Operating permiUmonitoring plan requirements (Compliance component 94) – 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 he made due to unknown conditions during system construction, possible abuse of the system, <br />inadequate maintenance, or future water usage_ <br />By typing my naive below, 1 certify the above statements to be true and correct, <br />used for the purpose of processing this form. to the best of my knowledge, and that this information can be <br />Business name; S� <br />Inspector signature:Certification number: <br />7 <br />(This document has been electronically signed) License number, — �– ' . <br />Necessary or locally required su Phone: r ,! <br />pporting documentation (must be attached) <br />❑ Soil observation logs ❑ System/As-Built ❑ Locally required forms ❑ Tank Integrity Assessment <br />❑ Other information (list): El Operating Permit <br />httpsi//www.pcm,state.mn.us 651-296-6300 800-657-3864 <br />Use your preferred -relay service Available in alternative formats <br />wq-wwisis4-311? 4/18/2021 <br />Page 1 of 4 <br />