Laserfiche WebLink
f �/ <br /> M�nne�ot� PoNution Compliance Inspection Form <br /> Contrvl Agency <br /> E�dstirMg Subsurfac� Sewage Treatment Systems (SSTSj <br /> 5�0 Lafayette Road North <br /> SL Pat�i,MN 55151-4194 ��1'�:���� <br /> Inspection r+esults based on Minnesota PoNutron Control Agency(MPCA) For locad Vaclang purposes: <br /> r�������_���requ;�ments may a�o a�p�►. R EC E I V E D <br /> Submit completed form to Loca1 Unit af Govemmerrt(LUG)arrd sysbem o�rt�er AUG 1 1 2014 <br /> within 15 days <br /> CITY OF ORONO <br /> System Status <br /> system s�on aate(mm/adhrnry): — , � "° �o "��/ ��� <br /> l�Compiiant—Certificate of Compliance ❑ �ncomptiant—Notice of Noncompiiance <br /> (Valid for 3�ears trnm reportrlate. w�ess shorter Sme (See Upgrade Requiiements on pag�e 3) <br /> frame ouUined in Lora!Ordinance.I , <br /> Reason(s)for rwncompiiance(check a��appllcaWe) <br /> ❑Impact on Public H�tth(Cornpiianoe Component�1)—Im�ner►t threat fo pubfic hea/tie a�safety <br /> ❑Other Com�ianoe Conditions(Compliance ComPon�r+t�k3j—lm�t th�at ta puWic health anal safety <br /> ❑Tank Integrity{Co►r�anoe Cam,ponent�2)—Fai7ing io prot+ect groundwate+' <br /> ❑Other Complianoe Condidons(Compfia►�ce Compor�errt�3)—Failing to P+oi+ect 9r�u�water <br /> ❑Soit Sepa�(ComPfrarwe Co+r►Ponent#4)—Far7ing to p�i+e�gnxa►dwai+er <br /> ❑Operating Persnitlmonitain9 Plan requiremer►ts(Comp�axe��o�a►e�►t�I—�� <br /> Property Information �����'"��: <br /> P��,►��: __ .3 8.� c�� �.t� ���� R��;�,: S��� <br /> Property owner. � � , Sr,v i�l�k ' � �/L owner's phone: � I z — `l� �" -� �'� 7G <br /> or <br /> Owner's representative: Representative Pt►a�e: <br /> Loca!regutatory authoritY v� �n v,�'£� Re�at�autt�r�y�e' <br /> : � . <br /> - - � `Yi1 a�.,n�d �v�� �/U��J�r rd. - <br /> Brief system descnpbon: --- <br /> Commen�s or r�ecommendat�ons: <br /> Certification <br /> l hersby ce►tify that al!the r►ecessary infa�ma6or+has beer►gaittered to determine the compliar�ae status�this sysfem.No <br /> deterrr»nation of fuhlre system perfon»ar�ce has been nor can be macwe due M urdo�own oand+tions dunng system oonstrudion. <br /> possible abuse of the sysbem,inade9u maintenance.or fidune waier usage. <br /> Inspector name: ��' � �number: � <br /> Business name: � Lic�se nwnber. S�O <br /> �������: Phone numb�: `7l03- �'7�'/��5�� <br /> �.�� ' <br /> Necessary or Locatty Req" red A�ach , <br /> L�t.Soil boring logs ❑System/As-built drawing ❑Forms per local ordinance <br /> ❑Other infio►mation(list): <br /> . 651-296-6300 • 800-657-3864 • TTY 661-2ffi-5332 or 800-667-3864 • Avai'l�le in�tematire forn�ats <br /> wwW.P�.StdtE.rtU1.US pbge 1 vf 4. <br /> wq-wwists4-34b • 6/4/14 <br />