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<br /> � w,�,; r�,�, �inn�sc�t� t�ollut�an �al"1'1�Jf ic�l'l��' �C1S��''C�1C1t1 ���'rC'i
<br /> '�,����d����.°, Contral Ac�ency
<br /> •�f"i���":'. I��istin �itibstuwfac� Sev►ra e+ '�"r��#rt�ent S s�enrws S57S
<br /> 52p Lafay�tt�F��ad Nprth � ” � � � �
<br /> 5t.Pta�al�A�IN 55155-h19A Instructions on page �
<br /> Parcel number: For Local 7racking Pur�oses�
<br /> System stafus� � �nmpilant � Nonromplfa�it
<br /> (J�aseci on Al!r,or�ip!la��ce�e�ulre�ner�ts)
<br /> Sn,�att�rt�ry �or�rn
<br /> P�raper�y Nn�arma�iar�
<br /> Property awner n�me(s): �'� ._..:.---�D�����----------T...._.,..�
<br /> .___,_.��,�._......�-- -....�.�.—
<br /> PropErty�ddress: __�_,t'4S5_.,.�__'�s_�__ '��-���i7'��"4-- 'C7�-�_�7'(�s�.S-�C�.._,��.,.,..�,-------��-•---..,..
<br /> Prc�perty owner's 2ddl'ess(!f dfiferent): _
<br /> Couniy:_�-}��t���1„�_ t'ro�erty nwnpr phon�: �a�w.�"���,� Permltting authority: ���� ��r ��,�, _
<br /> Data sys#em con;tr�Gt�d: Q_�!�j��� R�2son for inspection' �'Q�j'''�"""".c�"'�'��f� 5�. .�'""� ..
<br /> �.,m�-=�. _��3 '�5��C'S'�ru�'�n o a�.5��r�s �fitc.�,� .
<br /> Sys�ern� R�es�ript�ior�
<br /> Brief system desGripkion; lL�vc?�I 4+���-f��-'+et�oo�„9��w��,tA�,i e aw,�e.+�'a??!�W�'����0.�:,�_��F�.\�'�
<br /> Local permit number: �`���- ���y, NumUer of bodrooms; ,� Design flow r�te: _ . �j��_
<br /> Is thc�system:
<br /> in Shoreland area? �Yes []No In Wellhead Protectiqn Ar�a7 �]Yes ��lo
<br /> An U.S. �nvironmental Proteckion Sysiem seruing Fi Minneso#a Department
<br /> Agency (�PA) Cl�ss V Irtjecfiort Well?[�Yes �No af I-leath (MDN)flcensed fa[ility? I�Yes �No
<br /> Cbt'11�1�i�ll�� StBtUs (13asQd on state requirements—additiona{focal requlr�aments tnay�Iso appty.)
<br /> 9ased on the information ga#hered and repnrted or�sitachr�d fQrms,the compliance status uf this system is(chmck one):
<br /> � Certffinake of Gomplianc�—valid untii (3 yer�rs from d�h�of�pvrt):
<br /> ❑ NaUce of Noncomptl�nc�- Fcar Noncompliant s�stems: ��
<br /> Tl�e rc�son far noncompll�nce!s:
<br /> --_.,. .. ----_..
<br /> 7his noncompl�ant system is c@asslfi�ed a�(clieck one belauv):
<br /> � Imminent threaf to public heaith 8�saiety � Failing to prv#oct grounc)water n Not in compllance with operating pormit
<br /> Ce��i'�iCa�lofl (Completecl form muat be submitted to the loaal unit of government within 15 days.}
<br /> !her�by cerili'y Ihaf s�J!the nt�c�ssary inf�ht��Son has been gethered to dete►mine the compliance stat�rs of tliis systom, No
<br /> determinellon nf futr�ro systQm perfonnance has b�en nor c:an be made due fo crnlcnown canditlons during sysfem r,a�s(r��ctlon,
<br /> poss(F�le abclse of N�e sysfon�, in�d9�u�ate n7aintenanr,e, orlerfure water us�ge.
<br /> Nanie: ��"�`�13�yi__'�..._.�•._._.�J.�-��1'�~'�i��S Certlficatio�i number: ��,Z__.... --
<br /> Business ticens��ame and number: �=� ''��j y,}..l.y�����'�?j`'�__. .,..�.��l�'�'��-1�t'7��0„�+(�_ or
<br /> �� ....
<br /> Name of local un€f of ov rnment-AG—_. ,_._,_.�.–
<br /> Sii�Rture; � ,� �� .,..,.,.. ,,.....
<br /> 9 - �r _____....�.._ I�ate: �''"'c�—La � � _
<br /> �:�quir�d A�tac��me�ts Inspector Comploto; Tkti� Insp�ction Re��art is pages lonc�,
<br /> Checlk compN�nce forms�ttachod: li I-lydraulie F�orformanoe f�Tank Integrlty �Soil Sepgration [I �per�ting f�ermlt f=orm(if
<br /> applic�b3e) �J Syglem cirawing/,n,s-built dra�Ning [],An a���gament of�ny local rnqu3rement9 th�t are difFerent frnm what i�requirer,{on lhls
<br /> f�rm '�}Sail Etoring Logs f�1 Abandpnment form(if�pproprlake) ❑Olher lnformatlon(Ilst):
<br /> Upgrade Reqt�ire�men�s (de�ived from Minn. Stet.§115.55)An fmm�nent tlu�a��lo putrlfc healfh end s9lefy(lT1�NS)must be�tpnraded,replacod,or
<br /> 1(s trsc rJlsconNnued wllhln ten months o�rwcetpl ol eliis nof�c�or w1tN7n a shar�er perlad!1 reryuJrr.d by 1oca1 ordlnenCe.If Il�e systr,m le fat!!nh to protec�pround
<br /> �M1�nfer, Ihr�y�fem must be upgrndr�,!"P.pJ�iGCI�,vrlfS 1�s�dlstontinUed wRhln fhe Ume requlreh hy foCe!ordlnance.!l en exlsting Syslem Is rtuf f�lling es J�lFnnd ln
<br /> lHw,and has a�!r^�.�(livp fnr�t nf deslgn so11 seperetfon, fhen ft�P Qyslero nABd not be upgreded,rep�lrod,repl2ced,orlts use dlscanUnul�d,n6lwf7N3tend/ng F�tly
<br /> 1or..�!ordfn�lnCe fhBt!s mqrP stllr,(, 17r1s proVlslOn tloes n6t appl}�to sysA�ms!n ShOfClA11tl&f69s, We!lhrnr(p�r��Cflon Ama3,oY fhoae used In conna�!)nn ivlih fnon,
<br /> hevc+rege,and lodging cstab!l�l�ments es delfned A�f(iv�.
<br /> wq-wwists4•31 Compfinnce lnspecrron Form for Exis(�ing SSrS
<br /> 4/1/08
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