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Oc,t, 12. 2012 10: 16AM No. 0962 P, 3 <br /> �t:��,�- Minnesota Pollution Compliance Inspec i <br /> �����,����� Control Agency t OC� FO�I� <br /> i 5�0 Lafayette Road North Exlsting�Subsurface Sewage Trealment Systems <br /> , �i.Pa�WI,MN 55t5S-4194 �$$'rs� <br /> Doc Type_'Complienc�and Enforcement <br /> Ir�trucdona: Ihspection results based on Minnesota Pollution Contrvl Agency(MPCA) For local tracking purposes: <br /> I'equirements end att2ched forms—add'Rional local requlremenls may also apply. <br /> Subm(t completed fonn to Local Unit of Govemment(lUQ)and system awner <br /> wlthln 16 days <br /> �� <br /> System Status <br /> System status on date(mm/ddlyyyyj: q �a,'� � �Z.,. � <br /> ❑ Compllant—Certifica�e of Compliance �.Noncompliant—Notice of Nancompliance <br /> (Valid for 3 yaers fiom report date,unless shorter dme (See Upgr�de Requi�mants on page 3) <br /> frame outlined!n Lacal Ordinence_) <br /> Reason�s)for noncomplian�e(check all appllcsble) <br /> ; � Impact on Public He�lth (Compliance Cflmponent #�)—Imminent threat to public health and sefety <br /> ❑Other Compllance ConCftions(Complieqce Component#3f—Imminent fh►eat to public health end safety <br /> ❑Tank Integdly(Compliance Camponent #2)—Failing fo protect g�undwafer <br /> ❑Othe�Compllanoe Conditions(Campllsnce Compnnent#3)—Failing to pmtect groundwat�sr <br /> ❑ Soil Seperation(Compliance Componenl #4)—Failing to pmtect groundweter <br /> ❑Opersting permiUmonitoring plen requlrerrlents(Compliencs Component #5)—IVcncomplient <br /> Property Informatlon Parcel ID#o�SecJTwp/Range: <br /> Property address: __�; 5 °� O (ec��.��.\�'��S��o�v� . C�ti''�ti1 V Reason for Inspaction: �'ra�,.-�:�✓, �s�•�; ,�, �f;�::�' <br /> Praperty owner: Owner's phane: <br /> or <br /> Owners representative: �..� �, �� � � Representative phone: <br /> Locel regulatory authority: L�--��( p� (�g=,o�tic7 _ Regulatory authority phone: ��-;1,4`� -4�o U D <br /> Brief system description: a-�I l�lo S��'�-S�(.� 'f��\�G- I t�c�c�^Z�.�9�����' �!-1 C���C'��`�' �• �.h„a o�� I u�e��u'�'o[,Y��'�, <br /> Comments or racommendations: � �������F`��� R� �i�yduf,,� Nv��;. <br /> Certification <br /> 1 hereby ce►tiPy that al!the necessery Information has bsen gathered to determine ihe FompUa�lce stafus of this system.,No <br /> determinatron of future system performence has been nor can 6e made due to unknown conditions dudng system construction, <br /> possible abuse of the system,lnaarequate maintenance, or future water usage. <br /> Inspedor name: �j�i�y(/�1 ,�, �j L'�11'Prt-�,��� Certification number: (�,a1 <br /> `�usiness name: 5 -` t� � 1, License number 3�i.+- <br /> inspector signature: '� '� - -�- /1i�� t.�q� _� � <br /> . ;�.• �.� �-� Phone number � ���_ <br /> t�eces5ary or Locally Requlred Attachments <br /> ���Soil borine logs �System/As-built d�awing ❑Forms per local ordinance <br /> :t�Olher intormation (list): 1.I�.�n.J ���I hf�� <br />