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• : . <br /> � ��i�nesota Pollution • • <br /> ���Y ��Compl�ance .Inspect�on F`orm <br /> �� Con�ral Agenty . <br /> � ��% � Exlstln Subsurtace Sewa y <br /> S2o E.afayette Road North 8 ge Treatment S stems <br /> 5�.P�uI,MN 55155-4194 � . . �SSTS� <br /> . Doc Type:Campllance and Laforaement <br /> InstrucUons: lnspection r�esults based on Mlrtnesata.Palfution Corrtrof Agency(MPCA) �or locai tracking purposes: <br /> requiremenks and atteched forms--addi�onaf 1oca1 requlrements may also apply. � <br /> Submft compieted fortn to Locai llnit of t3o�ernment(LUOy and aystem owner <br /> w[thtn i5 days � . <br /> System Status <br /> System status on date(rnmlddiyyyy): � --a -� � . . <br /> ❑ Comptiar�t—Certiflcate of Compllance (�Noncomp[iant--Notice of Noncompltance <br /> (Valld for 3 yaars from r�port dats,uMess shorter�me (See Upgtade Requlremenfs on psge 3) <br /> frame out!ln�d ln Lnca!Ortiinance.) . <br /> Reason(s}for noncompElance(check a!!appl(cable) � •. <br /> ❑ Impact on PublEc F4eslfh(Complisnce Camponenf #i}»lmmineqt ihreaf fo publfc healfh and safefy � <br /> ❑ Other Complfance CondiHons(CompJfance Compottent#3)—1mm�nenf thr�af to publ)c hsatth and�safa(y <br /> ❑Tan1c integrity(Compliance Component�#2)—Fa!!!ng fo protect g�undwafer <br /> ❑ Other Compliance Condltlons(Camplfance Comporranf�f3)--Falling fo prnfect groundwafer � � <br /> �Soi!Separatlon(Complfancs Comppnenf #4}�_FallTng to prr�ffect groundwafer � <br /> ❑OperaBng permifilmonttoring plan requiremants(Compllance Cornponent #5)—1Voncompllant <br /> Prope�y fn#ormafiion Pa�cet 1D#or Se�JT'wp/1�ange: . � , � , � <br /> Property address: a,��}.v �. ��� , �q,� �� Reason for lns � — � <br /> Propertyowner. � s,�•�, -LT".�—'_ pection: �4�-l�("( �_�.;� <br /> ar ►� �..Y�� l- �� , Owner's phone: �Z . <br /> — 7. I <br /> Ownsrs representafive: Representative phone: ' - <br /> Local regulatary authorSty: C,��(�( o l� d-�,� c�� � Re ulato authorl hon�: <br /> Briei system descriptlan: a-1 c� r, � � .. g ry� �p �-'��'�`�'O1 '4 „ p <br /> ' �. D� 'Q,.f v�n� � ► y� �� Ni v�J <br /> CommeREs or recommendabons: v.1�.C� y�, .�v�x �,��.�r��p�, , <br /> Certfif�cation . <br /> 1 hereby cerfify fhat all the necessary lnforma�on has been gathe�sd to defeimine fhe compfishce stetus of th)s sysfem. IVo <br /> determinaflon of future sysfem perfarmancs hss beeir nor can be made due to unknown candltlorrs dudng system consfrvcHon, <br /> possfble.abuse of the systsm,lnadequetv matnfenance,orfutuns yvsterusage. <br /> Inspector name: ��i�,,. L'�ti-�M�� Ce�tlficat�on number: _ •(o..a7 <br /> 6usiness name: 5 � �( Ucense number. �e�t� <br /> Inspector sfgnature: :1..= , Phone number. �'](o� —►.�o�� _� � <br /> Necessary er Locatly Required Attachments � <br /> {�Soi1 baring Eo�s �SystemlAs-built drawing [j Fotms per loca(ordinance <br /> ❑ Other,informaGon(iist}:_ .�. � <br /> WV�N.pt3�StatC,m(1,115 � 651-Z9b•6300 • 800•657•3864 • TTY�65i•182•3�3Z or 800-b57•3864 • Avallab(e tn altemat�ve tormats <br /> ..._....�_._, �. . .,�.,,�� <br />