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Parcel number: 27-118-23-44-0008 System status: ❑ Compliant � Noncompliant <br /> (as determined by this form) <br /> Operating Permit Compliance and Nitrogen BMP Compliance <br /> Compliance Issue #4 of 4 <br /> Applicability: <br /> Is the system operated under an Operating Permit? ❑ Yes � No If"yes",then complete item A, below <br /> Is the system required to employ a nitrogen BMP? ❑ Yes � No If"yes",then complete item B, below <br /> If the answer to both questions is "no", then this form does not need to be completed. <br /> Compliance questions/criteria: (Required) <br /> (Check the appropriate box) <br /> A. For systems with operating permits: <br /> Has all the required monitoring and maintenance taken place and does the monitoring indicate compliance with the <br /> permit thresholds? <br /> ❑ Yes ❑ No <br /> B. For a system that has a required nitrogen reducing BMP and does not have an operating permit: <br /> Is the nitrogen BMP in-place and appears to be properly operating? ❑Yes ❑ No <br /> Any"no"answers indicates noncompliance <br /> Date of observation: Reason for observation: <br /> Operating permit number: _ <br /> This form expires upon next inspection or in three years,whichever occurs first: <br /> Certification <br /> This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compliance <br /> Inspection Form for Existing Subsurface Sewage Treatment Systems. Observations, interpretations and conclusions must be <br /> completed by an advanced inspector, service provider,or maintainer(maintainer for holding tanks only). Completed form must be <br /> submitted to the local unit of government within 15 days. <br /> Property owner name(s): LUCILLE M OFFERMAN TRUSTEE_ _ _ _ — -- <br /> Property address: 1669 NORTH FARM RD LONG LAKE MN 55356 <br /> Property owner's address(if different): <br /> County: Hennepin Phone: <br /> 1 hereby certify that 1 personally made the observations, interpretations and conclusions reported on this form and that they are <br /> correct. <br /> Name: Mark J Hayes Certification number: R5013 <br /> Business license name and number: Minnesota Geotechnical Services, LLC MPCA#L3203 <br /> or <br /> Name of local unit of government: Wri ht Count <br /> Signature: ��/ ��� Date: 6/16/9 <br /> wq-wwists4-31 Comp(iance Inspection Form for Existing SSTS <br /> 4/4/08 <br />