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;:,�.�:r� �I��hnesota Pollution COrT�I l�ance .inst�ection For � <br /> ��� Con�rot Agenty � t' m <br /> � 5�0 La�ayette Road North ��ti�g 5���� ��9e 7'reatment Systems <br /> s�.Paui,MN SSt55-4194 �SSTS) <br /> Doc Tvpe:CamWa►�e ar►a E►ilF�emerrt <br /> Instructlons: InspecEion resuMs based on Minnesota PoNuHon Controi Aaency{MPCA) Far locel tracking purposes: <br /> requirements and atta�forms-additianal loc�if requirem�ts may afso apply. <br /> Subm(t comp(et�ed tonn to Locat Unit of Oovemmertt(LUO)and syst�em owner <br /> within 15 days . <br /> System Status <br /> System status on date(mmlddfyyyy): /(J-a� -�s� <br /> �Compl�ant—Cerdflcate of Compltance ❑ Noncompiiant—Notice of Noncompliance <br /> {1/apd for 3 years firom report date,unless shorter tlme (Ses Upg�de Requlr�mertts an page 3) <br /> trame outlJned fn Loca/Oroflnance.} <br /> Reasan(s)tor nqncompliarfce{chsck all appllcab/e) �� <br /> ❑ Impact on Public Health{Complfance Componeni #i)-lmminer►t thrvat te publlc hea�h and safi�ty <br /> ❑Other Compll�oe Conditlons(Corr�llance Counponent#3)-lmminent tt+�at fo publk health and sefety <br /> ❑7ank 1nts8riiY(Complfance Component �2)-Falqng to protec..Y grtwr+dweter <br /> ❑Other Campliance Conditions(Corr�pllarrce Component�3)-Fa!ling to prt�fect qroundwafer � <br /> ❑Soll Separatlon{Complfar►c�Componarit #4)-Faflfi9 to Prr�tect groundwater <br /> ❑Operatln�permitlmonitoring plan requirements(Comp!lance Component #5)-Nor►complfant <br /> Property Ir�formation paro�ir�or ser�rwprr�an98: _��rf�u�,,�, �,c�• <br /> Properly addreas: _3 5 7 S Gl�'�,�C1�3-.��i�. ��c� Reason far inspec�ion: � �Q.,A��SF� <br /> Praperty ovmer: Owners phor�: <br /> or � <br /> Owne�'s representaHve: P'�J��'V' .�ii��i'aruC� Repres�tetive phone: ��,�Z �a lr���}014 <br /> t.ocei r�egulatory atrtt�ority: L�.'C� t9� d4�(9�Lc) Regufetory authortty phone: g S2-�aW9 - �Flov o <br /> Brief system descx9ption: ' � • <br /> Comments or reoommendations: <br /> Certff�cation <br /> 1 ha�by certity ihat al!the necessary Informadion has bser►gafhered fo determine the canmplfence sfatus of thls sysfsm,No <br /> determinadon of lufur�system performance has besn nor cen be made due to unkno�m conditlons dudng sys#em oonstrucilon, <br /> posstble.abuse of the system,Inedequste mafni+�nanve,or hdure w�ter ussge. <br /> Inspector name: ��y(l�.l +�.,���t!'Prh��DQ� Certiftc�tion number. f�,..a.7 <br /> BUsin8s8 n8m@: -' � UC@t188 RWfIbBT: -- -�e�-71.�- <br /> Inspedoc signature: ...- ,. �..�--- Phone number. �{d� --4.�-�-�, �� <br /> Necessary or locally Requ�red Attachments <br /> �Soil boring fogs �System/As-bu�t drawing (]Fo[ms per local or+dir�r�ce <br /> ❑Other{ritormatlon(iist): . <br /> www�pc�.state.mn.us • 451-29b-4300 • 8Q��657•3864 • Ti'Y 651•Z82-5332 or 80o-657-3864 • Avaitabte in aitematNe formats <br /> ►,�-�t�,-3r . rn4irz <br /> � <br />