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May 02 2015 09'44AM HP FaxRusty Olson 7634988290 Page 2 <br /> ��� cnnesota Polfution <br /> CpntrolAgency Compliance Inspection Form <br /> 5 �0 Lafayette Road North Existing Subsurface Sewage Treatment Systems <br /> St Pau1,MN 5515S-4i44 (,'1T'O �gSTS� <br /> , �. <br /> F�p Doc Type. Compliance and Enfo�ement <br /> •��pio <br /> �V <br /> r---- <br /> - -- - - <br /> Instructions: Inspection results based on Minnesota Paflution Control Agency(MPCA) , For local tracking purposes: <br /> requirements nd attached forms-additional lacal requirements may also apply. I i <br /> Submit com leted form to Local Unit of Government(LUG�arsd system owner <br /> within 15 da s I � <br /> System S tus <br /> Systerrt status on date(mm/ddlyyyy): 412fi12015 <br /> � Co pliant-Certificate of Compliance C Noncompliant- Notice of Noncompliance <br /> (Va id for 3 years from reporf date, unless shorter time (See Upgrade Requirements on page 3) <br /> fra e outlined in Local Ordinance.) <br /> Reaso (s) for noncompliance (check al!applicable) <br /> ❑ I pact on Public Health (Compliance Component #?)-/mminent threat to public health and safety <br /> ❑ C�ther Compliance Conditions (Compliance Component#3)-lrnminent threat to public health and safety <br /> i <br /> ❑T nk Integrity{Compliance Componenf #2j-Failrng to protectg�oundwafer <br /> ❑ ther Compliance Conditions (Compliance Component#3J-Fadrng to protect groundwafer <br /> ❑ S il Separation (Compliance Cornponent #4)-Failing to protect groundwater <br /> ❑ perating permiJmonitoring plan requirements(Compliance Component #5)-Noncompliant <br /> i <br /> Property 11f01'111dt1011 Parcel IDt1 or Sec/TwplRange: 231172323�036 <br /> Property addr ss: 180 Big Island, Orono, MN Reason for inspection: Property Transfer <br /> Praperty own r: Mark Myers Owner's phane: <br /> or <br /> �wne�'s repr sentative: Gregg Larsen Representative phone: 612-719-4477 <br /> Local regulatdry auihority' City of Orono Regulatory authority phone: 952-249-4600 <br /> Brief system escription: _1-10Q0 and 1-500 allon lift station and 660 square feet oT chamber per city records <br /> Comments or recommendations: <br /> Certification <br /> 1 hereby certi that all the necessary inforrnatron has been gafhered fo defermine the compliance status of this system. No <br /> detennination of future system performance has been nor can be made due to unknown condih�ons during system construction, <br /> possi6le abus of the system, inadequate mainfenance, or future wafer usage. <br /> �nspector na e� Joseph J Olson Certlfication number: 1255 <br /> Business na e: Rusiy plson's Soil&Perc.Testinq _ License number: 810 <br /> Inspector sign ture: Phone number: 763-498-8779 <br /> Necessary or Local(y Required Attachments <br /> � Soil bori g logs � -built drawing ❑ Forms per local ordinance <br /> ❑ Other inf rmation(list): <br /> www.pcastate. n.us • 651-246-6300 • 800-657-3864 • T'fY 651•282•5332 or 800-657-3664 • Available in altemative formats <br /> wq•wwists4-31 �• 1l24/i2 Page 1 of 3 <br />