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Property Address: �R U_�j 4.��. liz,11;1 <br />Business Name° _ ;._,'{� yl t.t a 7_s C. <br />3. Other compliance conditions -- Compliance component #3 of 5 <br />Date: '7ffo-'2A. <br />3a. Maintenance hole covers appear to be structuraJy unsound (damaged, cracked, etc.), or unsecured? <br />❑ Yes' 0 No ❑ Unknown <br />3b. Other issues (electrical hazards, etc. ) to immediately and adversely impact public health or safety? ❑ Yes' RE No ❑ Unknown <br />*Yes to 3a or 3b - System is an imminent threat to public health and safety. <br />3c. System is non -protective of ground water for other conditions as determined by inspector? <br />3d. System not abandoned in accordance with Minn. R. 708(].2500? <br />*Yes to 3c or 3d - System is failing to ;protect groundwater, <br />Describe verification methods and results: <br />Attached supporting documentation: ❑ Not applicable ❑ <br />Yes' 9 No <br />Z1 Yes' PTNo 1A 1,A- <br />4- Operating permit and nitrogen BMP* — Compliance component ##4 of 5 ❑ Not applicable <br />is the system operated under an Operating Permit? <br />D Yes ® No If "yes", A below is required <br />Is the system required to employ a Nitrogen BMP specified in the system design? ❑ Yes 91 No If "yes", B below is required <br />8MP = Best Management Practice(s) specified in the system design <br />If the answer to both questions is "no', this section does not need to be completed. <br />Compliance criteria - <br />a. Have the operating permit requirements been met? ❑ Yes ❑ No <br />b, is the required nitrogen BMP in place and properly functioning? ❑ Yes ❑ No <br />Any "no" answer indicates noncomPliance. <br />Describe verification methods and results: <br />Attached supporting documentation: ❑ Operating permit (Attach) ❑ <br />https://www.pca.state.mr.us 651-296-630() 900-657-3864 Use your preferred relay service Available in alternative formats <br />wq-wwists4-31b • 4/28/2021 <br />Page 3 of 4 <br />