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MINNESOTA. P tp CONTROL AGENCYTION Compliance inspection report form 520 Lafayette Road North p rm 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 (MPCA) website at htt si www. ca.state.mn.uslsites/defaultlfles/w-wwists4-31a.ndf Property information Parcel iD# or Sec/Twp/Range: Local regulatory authority info: Property address: Owner/representative: Brief system descriptio System status Local trackingnumber: Reason for Inspection n: iuurl �.4 '1<C id (� l lduc�+��l �Jv�; >ws . � Owner's phone: trltl Q &)_. hi�vfl System status an date (mmlddlyyyy); ® Compliant - Certificate of compliance* (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. 7080,1500 as of system status date above and does not guarantee future performance. ❑ Noncompliant- Notice of noncompliance 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 (1TPH5) 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 #l2) - Failing to protect groundwater ❑ Other Compliance Conditions (Compliance component #3) - Imminent threat to public health and safety ❑ Other Compliance Conditions (Compliance component 43) - 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 permiUmonitoring plan requirements (Compliance component #4) - Noncompliant - local ordinance applies Comments or recommendations Certification I 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: Certification number: (This document has been electronically signed) License number; -3- Necessary or locally required su Phone:�?j�,fr�Strst� pporting documentation (must be attached) Soii observation logs 12 System/As-Built ❑ Locally required forms Tank Integrity Assessment El Operating Permit D Other information (list): k httPs://www.pca.state.mn,us 651-295-6300 800-657-3854 Use your preferred relay service Available in alternative formats wq-wwi5ts4-32b 4/Zg/Z021 Pagel 04