Laserfiche WebLink
11 C N CONTROL <br />A 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 Pca state mn us/sites/default/files/wo wwists4 31a pdf. <br />Property information <br />Local trackin number: <br />Parcel ID# or SecfTwp/Range: Reason for Inspection¢�� <br />Local regulatory authority info: (,y44 F [2V4)y Q T <br />Property address: � �,.��Ssc. sow vzz�, ww <br />Owner/representative: CJ�.1>l�� �7J11'�-�- Owner's phone: <br />Brief system description: p-l0vs� •.f mat>'%�1u°f,� tdt�t?g.1 pUwt. ,S✓)�t��~ +��� l�tv�3so S� <br />+9 3 S3Yra�aar� u4v>✓c� <br />System status <br />System status on date (mm/dd/yyyy): �6 _q --A e <br />W 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 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. 7080.1500 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 #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. 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 />l 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, I 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: C) - S-� V 7 <br />- Certification number: (;a <br />Inspector signature: - <br />License number: 12) �__ <br />(r6s document has been electronically signed) <br />Phone:'14n3 •�t !3/;i-3 <br />Necessary or locally required supporting documentation (must be attached) <br />® Soil observation logs System/As-Built ❑ Locally required forms ❑ Tank Integrity Assessment <br />❑ Other information (list): G)�� '��,.�ah.t & <br />9 Y ❑Operating Permit <br />https://www.pca.state.mn.us 651-296-6300 800-657-3864 <br />Use your preferred relay service Available in alternative formats <br />wq-wwists4-31b 4/28/2021 <br />Pooe 1 of 4 <br />