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�C.wu _ � . <br /> ,.� �T�tnesota Pollution -�pm �1anC ' <br /> ��._�. CQntroi Agency � e .l�nspect�on Form <br /> � 520 LaQayette Road North Exist4ng Subsutface Sewage Treatment 3ystems <br /> 5�.P�ul,MN 55155-4194 (SSTS� <br /> • Doc rype:Corripllance and E}rlbrcaement <br /> Instructtons: Inspec6on resufts based on Minnesota.Pollutton Contnol Agency(MpCq) For local tracking purposes: <br /> requirements and attached forms—additttonal tocal requ(rernents rrtay atao app[y. � <br /> Submlt ccmpleted farnt to Loca(Unit of Govsmment(LUOj and system cwner <br /> wit�(n 15 days <br /> System Status <br /> System status ort date{mm/dcl//yyYY�� q%'�.L-1�o . . <br /> � Compfiant—Certificate of Cornpliance ❑ Noncomp#iant-Not[ce of Noncompiiance <br /> (Valfd for 3 years from naporf dafe, unless shorter ffrt�e (See Upgt�de Requirements on page 3� <br /> frame out!lned 1n Laca!Omlinance.j <br /> Reason(s)for nQncompliance(aheck al1 appllcable1 � "_ <br /> ❑ f mpact on Pub�fc Health(Campfisnce Companen? #i j--!mm)�ent thraef fo public healfh and safety, <br /> ❑Other Compliance Conditions(Compllanoe Compc�nent#3)=lmminent thr�af fo public heafth and safefy <br /> ❑Ta�k(ntegr3ty(Comprance Component #2)_F����fo prdtecf gr�unclwafer <br /> ❑Ot�er Compliance Condittons(CompKgno��mponent#3 —fiaFrn b • <br /> ❑'�Soii SepacaUon{ComplJartc�Component #4j—Fa!!!ng to pmtect g p�r������Wafer <br /> ❑Operating permit/manitor#n tan �vn�gter - <br /> S P requirements(Compliance Gompqnent #b)—Noncompllan! <br /> Property Information Parc�i�o#or sscn�wp�a e: � . <br /> rr�r�rty address: 4��S�.��G � M �dP�2-L <br /> � �� Reason for inspection- <br /> Property owner: d� . • ����GS�� <br /> or . 4wners phone: � -a...- - �, .z. <br /> Owne�s represantativa � � . <br /> Local regulatory auth�rity: _L�,.(� �t� ���,.�� Represen#a�ve phnne: � - . . , <br /> � Regulatory authority phone; q a-�y.9 — <br /> Briefsystemdeacrlptton: �. '—) • Sti -��L-� `—"�-- �iedv <br /> Comments or recommendetions: �N > > � � . `��"�''� � ��as0 ' <br /> � 1�- !o rltst3 ��� ,S�Z� �nS2-�-:'S,3 �ro�No� <br /> Certification <br /> 1 haraby certily titat a/l the neces�ery InfomraHon hes bsen gather�rl to datentrlr�e the pwnp/18nce sfatus of thfs system. No <br /> daterminafion of future sysfem performance hss baen nor can ba made dtte te unJmown condltlons dur�ng system consfruct�on, <br /> poss16/e.abuse offhe system,lrtadequate malnterrance,orfidur�wateruseg�e. <br /> lnspectorname: y{,(�y(� 1 ,� l����,�� �� . <br /> Busirtess name: 5 -� .( Certtftcetion number. .(. . <br /> Inspector signature: •�, �i�ense number: <br /> � �"'`M' Phone number. � <br /> Necessary ar Lo�atly Required Attachments � r � <br /> �Soi1 boring lags �SysfemiAs�i{t drowEng (]�o�g <br /> []Other irrforma�on(list): f�(�al ordinancs <br /> �rn,p����t�t��mn�u� • ��1-z94•6�V4 i ��45T•3064 � ��6��•���33Z or�•b�l-3d64 � Ay�i�able�altemat�e f4 a <br /> wg�wwrars4-31 • t 124�11 rnl � <br />