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� May. 14, 20'3 1 r;� ' 2A��� �ti'o, 1696 F, 4 <br /> � ����� �AIIPYtnesota Pollution Compliance Inspecfiion Form <br /> � � ,��� <br /> �`��`��guw`� Controt Agency <br /> k��;�,�� <br /> S�0 La(�yette Road North Existing SuhsurFace Sewag�Tr�atmgnt S�rst�ms <br /> 5�P�ul,MN 55TSS-4194 �S�TS� <br /> - Doc Typa:Complisnce antl EMorGement <br /> Inst�uct�ans: lnspection resulis based on Minnesote Pollution Conirol Agency(MPCA) For local tracking purposes: <br /> requtrements and attached forms--additfona!IaCal requirements may also apply, <br /> Submtt completed fotm to Local Urtlt of Government(LUQ)and system owner <br /> wlthEn 15 days <br /> 5ystem Status <br /> System status on date(mmldd/yyyy): � �,-g�l� <br /> �Cornpltant—Ce�tificate of Complia�ce ❑ Noncomplfant w Notice o#Nonaompliance <br /> (Valid for 3 years fiqm reporf date,unless shorter time (Se�Upgrade Requlr�ments on page 3J <br /> frame oudlned in Local Orrllnance-) <br /> Rea�on(s)for noncampllance(check aIl applicabl�) <br /> � Impact on Public Health(Complience Component #1)-Imminenf fh�at to public heaRh and sBfe�+ <br /> ❑01har Campllance Condltlons(Complience Comporrenf�k?)�-Imminent thr�at to publfc health and safary <br /> �7ank Integnty(Compliance Componenf #2)-FalUng to prot�ct qroundwater <br /> �4ther Compliance Copditlons(Complience Componant#3)-Feiling fo prt�tecf groundw�ter <br /> ❑Soil Separation(Compliance C�n'+ponent �4J,Feiling b profecf groundw�fer <br /> []Operating perm�t/monitoring plan requlrements(Compllance Component #5)-NonGompliant <br /> Araperty Information paroel ID#or SsclTwplRange: .�.L¢�t.�l� C� �. , <br /> Property address: a.��5 Lo� ►�a'o�. . �1?� Reason far inspection: ��4¢��(�(T�1�►��.,' <br /> Property owner. _ � Owners phone: <br /> or <br /> Owners representative: �, _ ����C��`.1�1-�uy�.�-. .� ��.'�� _ Repres�ntetive phona: �S�-,'-��5�'" q ao 7 <br /> LoCa1 regulekory aulhority: Cy�-C�( o�r a� Regulatory authoriry phone: q_5 a-a�t�i_f NlaUc� <br /> Briefsystemdescrlption: �-1�r9o �a1 5���� 4�k►.i�c.�7c7�w.,1''i,sw�p�i-�� �'� c. �s a�n �.►��. � <br /> COmmentsorrecommendations: �a2,���0� '� y'C3�a�eca«.+� Nb'rn�. g�n 5'�' <br /> �, <br /> � , , <br /> Certifjcation <br /> 1 hereby certiiy fhaf a!1 the necessery infomta8on has been gafhered to datermine the Compll&Rce stafus of this system.No <br /> det�rminatron of(uture system pelfom�ance has been nor can be mada due to unknown condilions during system conshvcfion, <br /> possrbfe a6use of the system,inedepu�fe malntenance,orfutur�w�ter usage: <br /> inspector name, � � G Certiflcatlon number: (p a.!�j _________ <br /> Business nams: � � Llcense number: ��- <br /> Inspector signature' W ,� ,� �-..�" Phdne number: ��� r�q�7 -?�5�(0 <br /> Necessary or Locally Required Attathments <br /> �Soil boring logs �SystemlAs-buiit drawing ❑Forms per local ordinance <br /> p Other information(list): , <br /> wv�w,pca,state.mn.us • 651-296-6300 • 800•657•3864 • TTY 65]-182•5332 or 800•657-3864 � Ava►lable in attemative formats <br /> wq•wwrsts4-3! . i/�4/}2 <br />