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Property Address: tel,, <br />Business Name- o_) �, J it I ( Date: <br />3. Other compliance conditions — Compliance component #3 of 5 <br />3a. Maintenance hole covers appear to be structurally unsound (damaged, cracked, etc.), or unsecured? <br />❑ Yes* B No ❑ Unknown <br />3b. Other issues (electrical hazards, etc.) to immediately and adversely impact public health or safety? [❑ Yes* ❑ 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. 7080.2500? <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* ❑ No <br />�t <br />En Yes* [?No <br />G' <br />4, Operating permit and nitrogen BMP* — Compliance component 44 of 5 El Not applicable <br />Is the system operated under an Operating Permit? ❑ Yes Cl No If "yes", A below is required <br />Is the system required to employ a Nitrogen BMP specified in the system design? ❑ Yes ❑ No If "yes", B below is required <br />BMP = 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? 0 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.mn.u.s 651-296-6300 • 800-657-3864 + Use your preferred relay service Available in alternative formats <br />wq-wwi5ts4-3Ib • 4/28/2021 Page 3 of 4 <br />