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10/i6/260� 20:42 9527586278 ADVANCED ONSITE INC PAGE 63
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<br /> �•-:.�;•:'��; Mir�nesota Pajlution
<br /> ���=� Control Agency Cc�mplianc� Inspection For �n
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<br /> 52a Lafayette Road l�orth Existing �ub�urFace Sewag�� V'reatment Systems (SS S)
<br /> St Paul,MN,5155-4�9a
<br /> Parcel number For Lo�al Tracking.Purposes;
<br /> System status: �C�mpliant �..J Noncompliant
<br /> (dased on all corrfpliance requirrromentsJ �� � �
<br /> aummary Ferrri i
<br /> Property Informa�ion . � �
<br /> PfOperly ownor namo(s): �I�'�'/� "� �� /� �lJ�; ,...,,,�,..,
<br /> Property acldress; ��_��_��,n��� _ ^ /�/1 �� � ���'
<br /> Property ow r's address (if different): _.._T .._ � ,��� _ . �
<br /> County: Property owner phone: ���,��� Permitting authority: _ ' �.�
<br /> Date system const �ctcd: 00 Rea:Son farinspection: �f� !� r'p�j�7` :" I�.�
<br /> 5,ystem Descript�on �
<br /> Brief system descripiion: �� ,�C�IOQ (��p�� � �'S� �` ,�`���/�r�/�i09,1
<br /> Local parmit numhcr: AlumhPi nf hPdr�nmc: � nesifln flow raie: ��3����',[`�'+`,�
<br /> Is the system: lpQ3 (��� �
<br /> Ir,Shoreland area? ❑ Yes �IVo In,W�Ilhead P�otection Area? ❑Ye.s f�Nn �
<br /> An U.S. Cnvironmental Protection System serving a Minnesota Dep�rtment �
<br /> Agency(E P A)C lass V In Jec tion We l l?(]Yes �No o f Heath (MDH) licensed fac9lity? ❑Yes �Na �;
<br /> �OfT1PI1df10E' StatUS (Based an state raquirvments–addilional local requirements maY also apply.)
<br /> Based on the information gathered and reported an attached forms,the compliance skatus of this system is (check one):
<br /> �Cenificate of Compliance–valid uniil (3 years frr�m dat� of repo�!)� ����� ^
<br /> [] Noti�e of Noncompliance-For Noncompliant systems: ��
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<br /> The reason for noncomplEance is: _�, _ _ __ M� �L'
<br /> This nancompliant system is classified as (check one bclow): I�
<br /> ❑ Irruriinent threet to publlc healih& salety ❑ Failing to protect ground water Q Not in compliance with operating p�!I�mit
<br /> �C�t1flCati0fl (Campleted form must be submitted to the local unit of government within 15 days.) j �
<br /> 1 hareby certify that all the necFssary informetion has bean gathered to determino ths Compliance status o1'this systOm. No 1
<br /> determinalfon offufure system performBnCo has beQn norcan be madc duQ fo unknown conditions during system constructio.,
<br /> pOSSibJe abu�of t�, lnede�to m �nfe i anca, �r li�lurr.. watar usage. r '
<br /> Name= % �� •� Certificatfon number; 1���6���
<br /> 8usinpss lir.anca namP and nu r. ��v/�d1�f��i��� � __� �t� . �j.{
<br /> Name of local unit af gove . � �
<br /> : �` —
<br /> �ignelure� , f�ate: � --����_
<br /> � f�equired Attach e�t5 InspQctor Compleie:This (nsp2ction Report is �pagec Io�1D.
<br /> Che�k eomp�ce�orms attached:�Hydraullc Pertormance �Tank Integrity ,�Sail 3opsration [� Oporating Permit Form(i! (
<br /> appllcable) System drawinglAs-built drawing �An sssessment o(9ny local requirements Ihei are difforenl from whal is requlred on�iis
<br /> fnrm �Soil Boring Logs Q Abandonmenl form (If approprialo) [J 01he�infortnalion (lis{): '
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<br /> . . ,_,.----.._...._............. .. . . .__--_ —____... . .. _ ..__---�--...,,.-----......:,.........-..__.-------..__.........,,...r- ---.... .----�- --
<br /> Upgrede Requ irr�men{s (derlved/rom MJnn. Sta�, § >�5.5,7 An fmmin4nf tl�rnp��p pi+h�lc hca/f�arrd aolp(y�ITp/�;�mus�oo upgrAtled,reploce i or
<br /> !ts use dlsaontlnued WJ1�In fe�rnOnths of recelpf 0!this noUce or wlJhm a xhnrivr nArinrV Y Mry,�;,,�n by/ocnl ordlnaney,J!tho oyofcm/,7/p!lmg to protec�gro�n
<br /> waler, !Do system musl be upgraogd,/epleced,orits uae d(sCon!inued uvithln►h�e C�me iequired by local orCrnarlce.!f en ex:$fin9 sysfem./s nof�8i/Mg as'Oofin 'in
<br /> law,and hes ef Jeesf Iwo lCol of design 5oll sepa�2fian,�hen thP Systom r�eed not b�upDrador/repeired,rep/QCcd,or if5 use dlsCOn�inued,nonvflhsfend�ng s �
<br /> lOCalordinance the�fs more sfr�tf, This prvvlslon Qogs nof apply fo sysfe!ms i�shorelend areas,Wr,llh6ad Arotecrlan Aneos,orthoae usod in�onnection wifh �od,
<br /> beverage,Bnd IodginD esfablishmenfs e8 dr�/inad rn law. �
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<br /> �YG-Wwists4-31 Compliance Inspection rorm�or-Existinq 5I7'S
<br /> �s�/1/08 •
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