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� , <br /> � r Minnesota Pollution Compliance Inspection Form <br /> �' Control Agency <br /> 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems (SSTS) <br /> St.Paul,MN 55155-4194 Doc Type.•Compliance and En/orcement <br /> InspeCtion results based on Minnesota Pollution Control Agency(MPCA} For local tracking purposes: <br /> requirements and attached forms—additional local requirements may also apply. <br /> Submit complefed form to Local Unit of Government(LUG)and system owner <br /> within 15 days <br /> System Status <br /> System status on date(mm/dd/yyyy): 5/21/2014 <br /> � Cornpliant — Certificate of CompliancE ❑ Noncompiiant — Notice of Noncompl'rance <br /> {Valid for 3 years irom report date, unless shorter time (See Upgrade Requirements on page 3.) <br /> frame outlirred in Loca!Ordinance.) <br /> Reason(s)for noncompliance (check all applicah/e) <br /> ❑ Impact on Public Health (Compliance Component#J)—Imminent threa7 to public health and safety <br /> ❑ Other Compliance Conditions (Compliance Component#3)—Imminent threat to public hea/th and salety <br /> ❑Tank Integrity (Compliance Component#2)—Failrng to protect groundwafer <br /> ❑ Other Compliance Conditions(Compliance Componenf#3)—Failing to protectgroundwater <br /> ❑ Soil Separation (CompJiance Component#4)—Failing to protect groundwater <br /> ❑ Operating permiVmonitoring p�an requiremenis (CompJiance Component#5)—Noncompliant <br /> Property lnformation Parcel ID#or Sec/Twp/Range: <br /> Property address: 888 Dakota Ave- Orono ___ Reason for inspection: sale <br /> Property owner: Byron Calderon __ Owner's phone: 763-478-1234 <br /> or � <br /> Owner's representative: Representative phone: <br /> Local regulatory authority: City of Orono Regulatory authority phone: <br /> Brief system description: 2 - 1000 Septics& 1000 gallon Pump, Mound _ <br /> Comments or recommendations: <br /> Should contact electrician to fix electrical at tank-not a health threat <br /> Certification <br /> !hereby certily fhat al!the necessary rnformation has been gafhered t�determine the compliance stafus of this sysfem. No <br /> determination of future sysfem performance has been nor can be made due to unknown conditrons durrng system consiructron, <br /> possible abuse of the system, inadequate maintenance, or luture wafer usage. <br /> Inspector name: Josh Swedlund Certification number: C1659 <br /> Business name: Swedl Se �S ce License number: 2502 <br /> Inspector signature: Phone number: 952-873-3292 <br /> Necessary or L cally RequSred Attachments <br /> � Soil boring logs �System/As-built drawing � Forms per local ordinance <br /> ❑ Other information (list): <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TfY 651-282-5332 or 800-657-3864 • Available in atternative formats <br /> wq-wwists4-31 � 3/16112 Page i of 3 <br />