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MINNESOTA POLLUTION Com liance inspection -'CONTROL AGENCY p p ction report form <br />520 Lafayette Road North Existing Subsurface Sewage Treatment System (SSTS) <br />5t. 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 https://www.Pca.state.mn.us/sites/defaultffiles/wq-wwists4-31a.pdf. <br />Property information Local tracking number: <br />Parcel ID# or Sec/Twp/Range: _ Reason for Inspection <br />Local regulatory authority info: <br />Property address: 3 Ca <br />Owner/representative; 4E7 Owners phone: 3*an -.!;,j 3 -�- <br />Briefsystemdescription:-M"3Jc7 aj.+ SSP-(�c, C �Y_�, # 13Jo�af %IVV c� p.y�v�t� - <br />S `�S i �T'j Vol) c}; 4 tri >� V� �S9c�GtSf� ea1,100t_­ 'r -OF- 14 <br />System status <br />System status on date (mm/dd/yyyy): - <br />❑ compliant -Certificate of compliance" <br />(Valid fora 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. 7080.1504 as of system status date above and does not <br />guarantee future performance. <br />❑ 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 (ITPHS) 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 focal "ordinance or <br />under section 145A.04 subdivision 8. <br />Reason(s) for noncompliance (check all applicable) <br />❑ Impact on public health (Compliance component #9) - Imminent threat to public health and safety <br />❑ Tank integrity (Compliance component 1#2) -- Farting 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. 70802500 (Compliance component 43) - 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, t 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: I- <br />Inspector signature: <br />(This document has been electronically signed) <br />Certification number: (1,1 a 9 <br />License number; a3_�4 <br />Necessary or locally required supporting documentation (must be attached) <br />E2 Soil observation logs 1' System/As-Built ❑ Locallyre forms <br />required q ©Tank Integrity Assessment <br />l2 Other information (list): k Guar , <br />❑ Operating Permit <br />https://www.pcastate.mn.us • 652-296.6300 800-657-3$64 Use your preferred relay service Available in alternative formats <br />wq-wwists4-31b • 4/28/2021 <br />