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03/06/2012 13:25 7634988290 RUSTVS PERC TESTING PAGE 02
<br /> � Minnesota Pollution • •
<br /> Control Agenty Compl�ance Inspe.ct�on Form
<br /> 520 Lafayette Road North ��st��8 $ubsu�ia�e S�waga Troatment lysto�ns
<br /> SL Peul,MN 55155-4i94 �$$TS�
<br /> Doc TYpe:Con�tianae and Enhuoenrenf
<br /> �►tstructlor�: In�pecNon results based on Minne�ota PQlluti�on Conb�ol Apency(MPC� For local trackinp purpoaes:
<br /> requirements and atteChed form8—addfdonal Ivcal requiremenis may 81so epply
<br /> 8ubmlt complobad fvrm to Local Unit of Oavemm•rrt(LIfG)snd�y�mm Owner
<br /> vrlthln 18 da�rs
<br /> System Stetus
<br /> Systsm stv4�s on doEa(mm►dd/�IriYI: 915rZo12
<br /> � Compllant-Certifica�e ot Compllance ❑ NoncompNant- Notice of Noncompliance
<br /> (Velld for 9 years from report date, unless shorter tlme (See UpgredeReqWrements an page 3) -.
<br /> frama outJined in LocaTOraOinence.) -
<br /> Reason(s�for noncompllance(check al1 oppllcab/o)
<br /> ❑Impqct orl;public.HQalth(Compliance Component �k1)—Imminent thieat to pub/;c heelth and saliaty
<br /> []Other Compllanoe Gondftlons(CompllenCe C�mponent�.31—�mmineM thieat to public Irealth end salf�ty
<br /> °���' ::--`�Tank Irrt
<br /> e9rttY(CampAience Cornpav►er►! #2)—Failhg b p�tect gruumMreter
<br /> O C?ther CompRsnce C�nditions(Corr�l;�►rve Ca�mparent#r,�)—F�ng ro protect giwrr►dwater �.,
<br /> ;�.:...
<br /> ❑Soil Seperation(Covr�pliarroe Carr�ppner�t *4)—Faidn9 to P�o18Ct 9►A+�n�aler
<br /> ❑Operatfng peimit/monitoring plan requi�ments(Con�l(erx�e Corr�po,nent �.5)—IVoncomplierrf , ,
<br /> �rn.u'�� .�u"1 .. , ,
<br /> ..:°�.�j�.,� ._. , . ..
<br /> Prop�erty Inforrriation Parcei �ore or secirwPr�nge: o2-i 1�-zs,�-oo02
<br /> Properly address: 1465 fox 5t., Orono, MN _,,,,,_, , Reason for inspe�tlon: Property Transfer
<br /> Property owner. Colin BalmfoRh Owr�ers phone: _
<br /> or ..,.�_..
<br /> <....�er��rep�esentehve� Ma�ic G 'rei er_ Repreaentativ�e phone: 952�045888
<br /> Own � .
<br /> . , ,.. ._ .. .__. ...
<br /> Loca)�gulatory authority: Cit r�of Orono Re�ulabory authority phone: 952-249�600 .
<br /> 2-1250 gallon septic tenks,1-1250 yallon INt stadon and 680 squ8re feet af mound rockbed_pe�aty
<br /> Brief system deccriptfon: records
<br /> Commenta or.recommendations; ��_" , -
<br /> ��'SIP%►iH� i 6 � :J� S'�'":��a ,a1Y7K1iEfiik .,, � �I�11��`�J �
<br /> �, , � � I.tJ:'!�•'d4�'Y��CYr .�1.^, ,':�all'�a,' � � � „ ' �� "!" . �� � �',�
<br /> i
<br /> Certification � � � ,
<br /> 1 he►eby oertllj�that ell the neceasary fi►forma6vn has be�n gethered to detertnirre the oanp/fance stetus of this system. No
<br /> determinehion af h,ture system perfnm�anc�has be�i�r�'i�wr can be rtrade due ro unkr►own c�orMltlons duMng system aanshuctian,
<br /> possible abua�s�of the system,inadequAl�a mai►�ter�a�cx, orli�[u�w+et�srusaqe.
<br /> Inspector neme: �Joseph J Otscm :��=:.�":� Ce�tificatbn number 1255
<br /> Bus'.,.�,...�..
<br /> iness neme: . Rus �Olson's Soil 8 Pe�.Testi"n""""" Lloense number. 810 '.
<br /> Inspectar signaWre: _ Phone number: 763-498-8�79
<br /> Nec sa or L ,.
<br /> � ,ry ocelly Requi�ed Attachments
<br /> � �, �
<br /> �SQiI bqri�g bgs ; . �System/Aa-built drewing ❑ Forms per local ordina�ce
<br /> {]Other infortnedon(list): _.
<br /> ��,�
<br /> 4vwW.pca.state.mn.us . 651-Z96•6300 • �657-3564 . T1Y 651•282-5332 or 60a657-36W • Available In aleemattve formats
<br /> wq-wwlscr.l-31 • 1/ZI/12 �_ Ar,o.f ot.o
<br /> i � ,'��a.:�
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