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07/68/2011 01:16 7634975611 SPTESTINGINC PAGE 03109
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<br /> `��"�" Minnesota Pollution Co�p�iance Ins �C���� �d
<br /> _ - �� �Co�ntro� Agency P rm�
<br /> 520 L�fryptte Ro�ti North
<br /> E�O�to�ng St�bsurf'ace ��wage Treatrr�en� Systerns (SSTS)
<br /> St.Paul,MN 551S5-A�9q Doc rype;C�mpll�nce Armr�p��ment
<br /> Instructions on page g
<br /> �'�mma�l �d�A'A1 (Completed form must be submitted to the local unik of gove�nment within 15 days,)
<br /> Parcel number
<br /> System status: �Complfent ❑IVoncompGant For Local Tracking Purpo�Qs: � —'-"'�
<br /> (based on all cnn►pliancp requl►�ments)
<br /> �'�op�rty Information - -�- -- _
<br /> Property awner n9me(s); ._V.1..LL.1.��1.��J1.�- -----, _ _,__ PropertY owner hone: .?� ,�
<br /> Properiy address: ^d p .�._��l.o_ O o
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<br /> I'rvperry owner eddre�.g(If dfff�r�nt): -. ~ _-_ �—_
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<br /> Coun : _ ...... ..---� --•�
<br /> ry �-��-�J,'�13-�-.. --,-- PoRnitting Authorlty: ,, ,f. ' � __�,.._
<br /> ��yS_.o���.___ -�
<br /> bete system constructed: _.Lq_q�.�_ ReAson for inspedioh:_ - �
<br /> — F�'���(�'�+����� .�.
<br /> System Descr1ption ��� ��~��'"���� ~
<br /> Brief sy�tem desc�lption: ��.o�.:SJ��!�3�'�__��rh�����..l�,�o aw�^; -S�.ti m �
<br /> Local pertnit number: Numbet of bQdrooms: ___,��_���Design flow�a�te���������
<br /> Is trie system: �- •—•-
<br /> In Shvreland erea? �Yes ❑ No In Wellhead ProteCtlon Area? �]Yes �No
<br /> An U.S. Environmental Protectlon System senring a Mlnnesote Depprtment
<br /> Agency(EpA)Class V In]e�tian Well?I�Yes �No of Weath(MDH)licensed facillty� L�Yes �No
<br /> CoRlpliallCe Sfidtus(,6ased on state requir�menfs-eddltio►��l lar.gl requirerqents mey a/so apply,)
<br /> Based on tlie Irrformafion gathered and reparted on attached�Forma,the compllance status of this system le(ch�ck one):
<br /> I�Certificate of Compliance-velld untU (3 yea►s trom dete of repo►t):
<br /> C�Notice of Nonc�mpliance-For Noncompliant systems: �y
<br /> The reason for noncompllance is:
<br /> --......:....._ -..� _,.. ..
<br /> This noneompllant 9y9tem is clas�lfled as(�heck one belowj: � � ^� `—"`-""
<br /> ❑ Imminent thre�t to public health 8 gafery ❑Failing to protect ground w�ter ❑Not in compliance wlth opereting permit
<br /> Cert�fication
<br /> I hereby certify that aN Nte necossery infiorma6on has been gathered ta determine t1►e cnmpliance aFet�us uf this sysfam. No
<br /> detentrinat;on oF�uh�rr�sys[�em perfvrmance has been nor ca�n be mada due to unknown candi6ons durfng�yatem�nnstruction,
<br /> — tem, Inadequat�meinienance, vr fufur�Water usa,qe.
<br /> S��v�i.i ' r
<br /> N mse:e a use� ie sys� -��1���_�-„ ----,...-•�-- Certification number lQ
<br /> �..
<br /> �uslness Ilcense n2�me and number: _5-'P���1�,�iJ C�, L�C,, �' 3�_�`�.����y�?- 351ob or
<br /> Name of local�anit of govemmerrt: �
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<br /> Signature; � - Date- i�.-`��"�� �
<br /> _..._...----...., _ --._...,._�_- —�
<br /> Requ�red Attachments ��
<br /> � Hydraulic Petformance Tank Ihtegrity ❑Operating Permit Form (;f appi;ca,bie�
<br /> � Soil Boring Logs Soil Seper�tion
<br /> � System drawing/As-built drawing ❑Any local requirements that are different from what is required on thfs form
<br /> ❑Othor informaHvn(Ilst): ,_,.__.. .,.,__
<br /> Upgr,�de RequltemeMs(de►�ved finm Mlnn_ 5'feC§ 9 95.55)An Imm/none H,►sAt M publ�IrealHr a�sart�{y(ITPNS)must be upgraded, �
<br /> �eplacod,or!(s use dlsconfin��d wlNfln tKrn rrronNis of►er.eipt of thls nofice vr wifhln a Shc�Rer pertod if requlred by Mca!oldinerw�e.II the system Is
<br /> fAlling to profect ground water,H�a sVst�snf nf��At Ae upt7raded,rspleeed, or fts usr�dl�ntlnued wfthfn f/re tlme rsqulm.d by Mca!ortNnAnr,y.lf nn
<br /> exlstMg system/s not falling es de!)neti In 19w, p�d has at least tu►Ao 1`eef of dasiyn�aoil b�aparet/on,Hren the system need nvt be upgeaded,�pefrtad,
<br /> replaCed, �rifs i�e di�:ontlniaed,nofWiH�st�nd/ng any lnael adinence fhet is morr�sMet This provls/on does not oppry b syPfems In shoralDnd
<br /> • e►oAs,Wellhead f�rolecN�n Ar�as,ar fhvse used in cannmctlon wlth food, bev�r�,qe,snd loaging estabNshmenfR as defined!n lew
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<br /> www-pCa.stete.mn.us • 6S1•296-d300 900-657•386! TTY 651-292•5337.or 800-G57•3Af•e • AvallahlA in alrvarne�i�...�.__
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