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� ����� MY�nesata�Pollution ' ' � • <br /> �� � ��om l�an�ce .lns ect�o.n �`orm <br /> ��;W Con�ral Agenty p p <br /> � 524 Lafayette Road North ��St�ng Subsueface gevyage Treafinent Systetns <br /> SI.Pau(,MN 55155-4194 � �SSTS� <br /> Doc Type:Compilance arrd,E�tor�eme»t <br /> instructfons: Inspection resuits based on Mlnnesota PoIlution Control Agency(MPCq) For IocaI tracking purposes: <br /> requiremenEs and attached forms-additlanal laal requlrements may also appty, � . <br /> Subm(t corrspleted form to Local Unit a�Govemment(LUG)and system owner <br /> withln i5 days • � <br /> System Status � . � � <br /> System sfatus ort date(mmlddlyyyyj; ��3�1 � <br /> ❑ Compliant—Certificate of ComplJance �Noncompliant-Notice of Noncam lianc <br /> {Valtd for 3 yesrs from report date,unless shorfer�me � P � <br /> frarne ouBlned/n Local Onl/nance.j f5ee Upgrade Requlraments on page 3) <br /> Reaso»(s)for nqncomppance(check m/!appllcahle) � , <br /> ❑ Impact on Public Health(Complisnce Companant #1}-(rnm)per�t thr�af fo pubilc health and safefy � <br /> ❑Qther Compi(ance CondiUons(Compllance Component#3)_Immtnent fh�eat fa pubilc health and safety <br /> ❑i'ank integrity(CompGance Companent#2)-Fafling fo protect grtwndwater - <br /> ❑Other Campliance Conditions(Compliance Camputtsnf#3)-Failinq fo protecf groundwafer � ' <br /> �Soi1 Separatian(Complfence Component #4}�Far7fng fo prvfecf grouadwater � <br /> ❑Operating permitlmon(toring plan requlremenfs(Comp/Iance Component #5)-Nancompliant <br /> Property lnfotmation Parpa(�!Q#orSecJi' �a e: <br /> Properiy address: �a,v s �,�� � � � �� � <br /> `�`�o`� "`�9��� Reason for insgectian: <br /> Property owner: � � � • � � ` <br /> or Owner's phone: � <br /> Owners representaflve: ;,C.C� Q,�IL��j,,�5�0� � ` <br /> Lo�al reguiatory authortty: C.�-(r( d� -��.,��� ' RBp�sentative phone: � � <br /> Brief system descrlptton: _ �� `Regulatory authodty phone: Z3 _ayo� _4�covo <br /> � 1 � � <br /> � n° �.' � iwo -� � _ . <br /> Commenfsorrecammenda�ons: S�s,�rn►5 w ..s-< �,oc�.y�,�c �.r� �,. ��, .�,� ��s����� 1�.�ti �,� <br /> , REW� ��s�.P��E.., � � . � 1 <br /> Certification <br /> 1 hs�by certify fhat ai!ffie necessary fnfomtaflon has been gatherad fo detemtine fhe complfance status af this system.�No <br /> deterrnrnation of future sysfem performance has been nor can b�made due fo unknawn condltlons during sysfem constructton, <br /> possi6le.abuse of the system,Inadequafe metrrtenarice, orfutur�yveterusage, - <br /> lnspector name: �f�y{j� � .!�� <br /> ----�.L'�hn��.._ Certif'ication number: _{o..a!J <br /> Business name: � -� �( Licetise numb2r. <br /> Inspector signature: .�� , ` • - ���' <br /> Phone numbec � <br /> �ta� ��k9� -�,�l t p__ <br /> Necessary ar Locatty Required Attachments � <br /> �•Soif boring loqs �SystemlAs•built drawing ❑Fo[ms per Iocai ardinance <br /> ❑Other.information pist}:_ _, . . <br /> WY}W.pCd.Stdte.m(1'US �_ 651•19b•630D • 80Q•657•3864 • TTl'�b5i•281•5331 or 80a651•3864 • Avaltabte!n aitemati�e formats <br />