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MINNESOTA POLLUTION Compliance inspection report form <br />CONTROL AGENCY <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 (MPCA) website at https://www.oc@.state.mn us/sites/defaultffiles/wq-wwists4-31a.pdf. <br />Property information Local tracking number: <br />Parcel iia# or Sec/Twp/Range: _ Reason for Inspection <br />Local regulatory authority info: [, t { ov 1� 0 <br />Property address: -1 ';t) Go A 7Z) <br />Owner/representative:Owner's phone- pho ;, - 6300 <br />� ne: "�� ��� .. <br />Brief system description: a - ego e 5y��•{� 4�N4� t g�� -�7xj , .fir ��G f� �� 4 <br />I DaY�7 <br />5�51'15 m uUI- r Or toX G 4-¢07IA20trl 14ol,•gir <br />System status <br />System status on date (mm/dd/yyyy): <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 1458.04, subdivision 8 is discovered or <br />a shorter time frame exists in Local Ordinance.) <br />°'iUote: Compliance indicates conformance with Minn. <br />R. 7080.1500 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 local ordinance or <br />under section 145A.04 subdivision 8. <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 93) - 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. 7080.2500 (Compliance component #3).- 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 />inadegtrale maintenance, or future water usage. <br />By typing my name below, 1 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: Cj - <br />Inspector signature:Certification number. <br />'�i .� • �� License number: ?LI <br />(This document has been electronically signed) Phone: u M <br />�t�4�y � r.. •c <br />Necessary or locally required supporting documentation (must be attached) <br />® Soil observation logs System/As-Built ❑ Locally required forms 0 Tank Integrity Assessment <br />El Operating Permit <br />l2 Other information (list): S}�� '%'� �FMI•J Ac Gk),i <br />https://www_pca.state.mn.us 651-296-6300 800-657-3864 Use your preferred relay service Available in alternative formats <br />wq-wwists4-31b • 41281202I <br />