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Oct, 22. 2012 11 ; 14AM No, 1004 P, 4 <br /> �.��� Mi�nesota Pollution • <br /> �- - ����;� Compliance Inspect�on F�orm <br /> ��., Control Agency <br /> `,��r."� Existing Subsurfaoe Sewaga Treatment Systems <br /> 5�0 La�2yette Road Norch <br /> 54 Pgul,MN 55155•4194 �$$Tg� <br /> Doc Type:Complienc�end EMo�Cement <br /> InstrucUons: Inspection resuke based on Minrtesote f?ollution Control Agency(MPCA) For local tracking purposes: <br /> requirements and attached forms—additEonql local requirements mey also apply. <br /> Submit completed form to Local Unit of GovernmenC(LUG)and aystem owne� <br /> within 15 days <br /> System Status <br /> System status on date(mm/ddlyyyy): °��a� -12 � <br /> � Compliant-Ce�tificate oi�Compliance ❑ Noncompliant- Notice of Noncompliance <br /> (Velid far 9 yea►s from report date,unless shorter�me (See Upgrade Requirements on page 3) <br /> frame oudined in Local Orolinance.) <br /> R�ason(s).for noncompliance(check ell appUcab/e) <br /> ❑Impect on Public Health (Complience Component #1)—Imminent threet to publlc health end safely <br /> ❑ Other Compli�nce Conditions(Complience Compor�ent�13)—lmminent th�at b public health and safety <br /> ❑Tank Irttegrity(Complience Component �2)—Failing to protect g�oundwatvr <br /> ❑Other Compliance Conditions(Complience Component#3)—Feiling to p►ntect groundwat�r � <br /> ❑Soil Separailon(Comp/iance Companent #4)—Felling to p►otect groundwater <br /> [] Operating permiUmonitoMng plan requirements(Compllance Component #5)—Noncomplient <br /> Property Information Paroel IDI�or SedTwp/Range: <br /> Properiy address: _�Q loC� �y�.�\,/��) \, � , , (��(� Reason for inspettion: C'�t'c9�;�;�'�� ��t!`}.;�r... - <br /> Property owner. _\/��„� yy a�G,��}U .___ Owners phone: <br /> o� <br /> Owner's r�presentative: RepresentaUve phone: <br /> Local�eguletory authotfty: (��-(�( p F Q�p'i��.,�� � Regulatory authority phone: �j�,/�.a,�}�� r�y��„dv <br /> Briefsystemdescription: � ��c� f, �y��i� �,� '�A��.S�4,, ,1c9�P�.,(i��lwl'�-'�iv�,.S �. <br /> , �- 4. 1�40v�ca �J ��1� � <br /> Comments or recommendalions: lu� � S,� ��1�'��c`� Sr7��'�� '("�V��' IG- '-!��E^��>'rFc�c�� 1-4��1 F':�. <br /> Certificatian � <br /> 1 he�by certly Ntat all the necesaery iqfo►matlon hes been gathered to determine the oompl�ance status of thls system.No <br /> determination ofluture system perfiormance hes been norcan be made due b unlmow�conditions duting system constnrcHon, <br /> possible ebuss of Ehe system,inedequete malntenance, ar future water usage. <br /> Inspector name: �i^�iy�il�i ✓��L��►�r�{��� Cehlficatlon number: _ .(o.,a� <br /> 8usiness neme: 5 � � License number: ��yy- ! <br /> {nspector slgnat�fe: � �.�� �' �-----•� Phone number: �p� —t�q� —� �� <br /> Necessary or I.ocally Required Attachments <br /> �Soll boring Iogs �System/As-built drawing ❑ Forms per local ordinance <br /> ❑ Other information(list): <br />