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� a �. <br /> ��� Minnesota Pollution • • <br /> ��r�� � Control Agency Compl�ance Inspect�on Form <br /> .,rLt�i:...'...:. <br /> 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems <br /> fiL P�ul,MN 55155-4194 (SSTS� <br /> Doc Type:Compliance and Enforcement <br /> Instructions: inspection results based on Minnesota Pollution Control Agency(MPCA) For local tracking purposes: <br /> requirements and attached forms-additional local requirements may also apply. <br /> Submit completed form to Local Unit of Govemment(LUG)and system owner <br /> within 15 days <br /> System Status <br /> System status on date(mm/dd/yyyy): �� -t� - ���. <br /> �� Compliant— Certificate of Compliance ❑ Noncompliant— Notice of Noncompliance <br /> (Valid for 3 years fiom report date, unless shorter time (See Upgrade Requirements on page 3) <br /> frame outlined in Local Orriinance.) <br /> Reason(s)for noncompliance(check all applicab/e) <br /> ❑ Impact on Public Health(Compliance Component #1)-Imminent threat fo public health and safety <br /> ❑Other Compliance Conditions(Compliance Component#3)-lmminent threat to public health and safety <br /> ❑Tank Integrity(Compliance Component #2)-Failing to protect g►aundwater <br /> ❑Other Compliance Conditions(Compliance Component#3)-Failing to protect groundwater <br /> ❑Soil Separation(Compliance Component #4)-Failing to protect groundwater <br /> ❑ Operating permiUmonitoring plan requirements(Compliance Component #5)-Noncompliant <br /> Property Information Parcel ID#or SecJTwp/Range: <br /> Property address: 4�,y 5 �.��p-p��,�/,� L�C}, U`� ?..�,5-� Reason for inspection: `"1'�QY�'-t.:-��� ����'w���<<;,�, �,� <br /> Property owner: �oN}_1 /.�p,�� S, Owner's phone: b l a_-��y _ ,..� -��a <br /> or - <br /> Owner's representative: Representative phone: <br /> Local regulatory authority: � L►�(�( O�' �z��,�<<� Regulatory authority phone: � ,�,'� ••• �.���-� - i,K�G;��� <br /> Brief system description: �.-1 a 5o a�,l S%'-�►cJ.-Cv�����S_ ��S p qa I G ar����x 1 k �`t oz�N� I c�`x t���'F'v c s�Y r:e.; <br /> Comments or recommendations: � <br /> Certification <br /> 1 hereby certify that a!I the necessary information has been gatheied to defermine the compliance status of this system. No <br /> deteRnination of future system pe�formance has been nor can be made due to unknown conditions during system construction, <br /> possible abuse of the system,inadequate maintenance, or future water usage. <br /> Inspector name: _�-{�y�i� ,� �L��-���� Certification number. (o a� <br /> Business name: 5 -' t� � License number: �e��.E. <br /> Inspector signature: (��r �'� i�"- ..----_. Phone number:. �{o� -�g� _ � <br /> Necessary or Localty Required Attachments <br /> �Soil boring logs � System/As-built drawing ❑Forms per local ordinance <br /> ❑ Other information(list): <br /> www.pca.state.mn.us • 651-296-6300 • 800•657•3864 • TTY 651-282•5332 or 800-657-3864 • Avaitab(e in altemative formats <br /> wq-wwtsts9-31 • 1/24/12 <br />