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�MINNESOTA POLLUTION CONTROL AGENCY p Com liance inspection report form M� 520 Lafayette Road North Existing Subsurface Sewage Treatment System (SSTS) St. Paul, MN 55155-4194 Doc Type: Compliance and Enforcement Instructions: Inspector must submit completed form to Local Governmental Unit (LGU) and system owner within 15 days of final determination of compliance or noncompliance. Instructions for filling out this form are located on the Minnesota Pollution Control Agency (MPGA) website at htt s://www. ca.state.mn.us/sites/def2uIt/fsles/w -wwists4-31a, df. Property information Local tracking number: Parcel ID# or Sec/Twp/Range: Reason for Inspection �{ Local regulatory authority info: Property address: 2\q\A �" 5 I;;� u Owner/representative:�.� `� j ,, , ��i�}+ � Owner's phone: _(012 ~ I t,— Brief system description: 15 CJ dot <044"o 1000 aga.Ay" tloA)�Sa- I tj �i fay System status \,>� uQA74- t-h*� k'zr, S A�— 41�<v5 System status on date (mmlddlyyyy): • ❑ Compliant— Certificate of compliance" 0 Noncompliant— Notice of noncompliance (Valid for 3 years from report date unless evidence of an imminent threat to public health or safety requiring removal and abatement under section 145A.04, subdivision 8 is discovered or a shorter time frame exists in Local Ordinance.) "Note: Compliance indicates conformance with Minn. R. 7080.9500 as of system status date above and does not guarantee future performance. Systems failing to protect ground water must be upgraded, replaced, or use discontinued within the time required by local ordinance. An imminent threat to public health and safety (ITPNS) must be upgraded, replaced, or its use discontinued within ten months of receipt of this notice or within a shorter period if required by local ordinance or under section 145A. 04 subdivision 8. Reason(s) for noncompliance (check all applicable) ❑ Impact on public health (Compliance component #1) — Imminent threat to public health and safety ❑ Tank integrity (Compliance component #2) — Failing to protect groundwater ❑ Other Compliance Conditions (Compliance component #3) — Imminent threat to public health and safety M Other Compliance Conditions (Compliance component #3) — Failing to protect groundwater ❑ System not abandoned according to Minn. R. 7080.2500 (Compliance component #3) — Failing to protect groundwater Soil separation (Compliance component #5) — Failing to protect groundwater ® Operating permit/monitoring plan requirements (Compliance component #4) — Noncompliant - local ordinance applies Comments or recommendations Lv,CX �, �Q►' 4041 K)4 r20 cavi ,4-y/t�r+ i `� aH5�5`v� �v, R•�,r�c.�.v( La�t3y. Certification 1 hereby certify that all the necessary information has been gathered to determine the compliance status of this system. No determination of future system performance has been nor can be made due to unknown conditions during system construction, possible abuse of the system, inadequate maintenance, or future water usage. 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 used for the purpose of processing this form. Business name: Inspector signature: (This document has been electronically signed) Certification number:,,_ License number: __a3)__4___-_ Phone: �,5.gr�.`,�t� Necessary or locally required supporting documentation (must be attached) 9 Soil observation logs [2 System/As-Built ❑ Locally required forms ❑✓ Tank Integrity Assessment ❑ Operating Permit ❑ Other information (list): https://www.pca.state.mn.us 551-296-6300 800-657-3864 Use your preferred relay service Available in alternative formats wq-wwists4-31b • 4/28/2011