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Parcel number S�sterr�stetu�. �
<br /> ------- -- -- 1 L, Com liant
<br /> --- p Noncompliant
<br /> (as determined by this form)
<br /> �=�a�'r�xa�;: � ' , b ._ . � .��;.rt����� �3►,��' ' �._
<br /> lJs .f.'iIF
<br /> a.JS��77C�);-�..L ?J.?'•si� tp6:` ;J•''
<br /> ,3;�nl icabilit��:
<br /> is the system operated under an Operating Pennit? ❑Yes �lo i;"»� " � � ,;. -,.
<br /> s , .;�vn comaltie i�,.� , .�, -aelo�v
<br /> Is the system rec�uired io employ a nftrogen BMP? ❑Yes No Ii"yes", chen corr;�lete iti�m 13, aeloµi
<br /> h`the ar,�tive��ta.Uoth�ues[`ions is "t,o'; :n�-;� �his fo�r.�t does notn�ecl Po be com.ole��d.
<br /> C�t;�1;�`e;_;Cet313:'il-e',i3/C;'ii�et'i�: (Required)
<br /> (Check the appropriate box)
<br /> A. For systems�vith operating perrnits:
<br /> Has all the required monitoring and maintenance taken place and does the monitoring indicate compliance�n�ith the
<br /> �ermit thresholds?
<br /> ❑Yes ❑ i�!o
<br /> B. For a system fhat has a required nitrogen reducing BMP and does not have an operating perinit:
<br /> Is ihe nitrogen B��AP in-place and appears to be properly opera"ting? ❑Yes ❑ No
<br /> �=,�._r ,;r�' _..., ,�:,��.it,.;ca�v_ ,.v.,��rr;>l,"�<�r.�
<br /> Da�e of observation: _ P,eason fvr obsen.�ation:
<br /> Operating permit number:
<br /> 1 his form e�:pires uj�on ne;:;i;�sj�ec't;cn ,�r;n��re� ;�ears. �r�hichever occurs first:
<br /> This form is to be completed and attached to ihe Surrnnary Form ofthe Minnesota Pollution Control tigency's(f�APCA)vem�?si�n,e
<br /> �<<§���'?'=" �-� :;�, _;,i�ti„r;,t't�s�,, ,c,;,�� �,,�� �,,;,o� �„�tA;-,�,, ��servaiions, interpreiaiions and conclusions must be
<br /> completed b;an advanced mspecto� seriice p-ovider or maintainer(maintainer for holding tanks only). Gompleted form must be
<br /> submitced to the iocal unit of government within 15 days.
<br /> Property o�Nner name(s):
<br /> Propert;raddress: ��„__��� �
<br /> Propertyo u�vner's address(i�different): '
<br /> County: �w� Phone: ---- —
<br /> �
<br /> /hereby certify that/persona/!y rnade the observations, interpretations and conclusions reported on this form and fhai fhey are
<br /> correct
<br /> Name: �p,(,,c,� � �,�E,,v Certifica on number: ��k�
<br /> Business license name and number: /�f,e.� `LCS / SG krJ �e�t�-,.• � ���
<br /> or
<br /> i'�1ame of local unit of government: (�,Q p
<br /> Signature:
<br /> �-� Date: �O � p g
<br /> 1�--
<br /> wq-wwis ts4-31
<br /> ��>>pg Compfiance lnspection Form 1`or E,�istin�SS/S
<br />
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