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10/24/2608 02:35 7634975611 SPTESTINGINC PAGE 03/09 <br /> • . <br /> �,;,:.,;;�:.;�„�: ��innesafiaPollution � CO pliance Inspe�ction �Form <br /> �.���* I� <br /> ��� Control Agency <br /> 3z01..afeyett�±Ro�dNorth �xi9ting Sub�u�irf�ce Sewage Treafin�ent Systems (SSTS) <br />� St Paul�MN 55155-419�A I Instruttions on page 7 <br /> I <br /> P�rcel number_ <br /> ' �For I.ocel Tracking Purposes: <br /> System st�tus: ■Compllent ❑Noncompliant <br /> (besed on ell complience requfierr�ents) <br /> �unwmary Fornn <br /> Rroperty I�format�on <br /> property owner name(s): �i��p��(l� '�4-1+f'flP�►a <br /> Property address: . 56�� --I_� 1}�..�'� a . <br /> Prope�ly own�r's address(If dift�rent): ,�_,,,, <br /> County:VY�4.1��1�,�.� ProPerty owner phone: -L �lo V O � Permi�ing authority: ,GxC� o�r 0401.1,CJ� <br /> Dale system construcled: �q-`�9' -- Reason for inspec�ion: ��, v <br /> � <br /> System pescription <br /> erief system descciption: �a��Q.���� b I � � �"a M��i..�q Ip�t ��� <br /> Local permit number. • � Number oF bedr4cros: _ �- _ pesign flow rate: ,,,�0 D <br /> Is the system: I <br /> tn shorelend area? �]Y�5 �No In W head Proteclion Area? �Yes �.No <br /> An U.S.Environmental Protectlon Syste serVing n Mlnnesote Depa�tinent <br /> Agency(EPA)Class V Injectlon Well?Q Yes ■No of We th(MDH)Gcen�ed facilily? ❑Yes � No <br /> CoR1�I�d11CF' S�atI1S(Besed on state requirements--addillonal�xsl requirements may also apply.) <br /> Based on the information gathered and reported on aitached fortns the CompHanee status of this�ystem is(chock one): <br /> , �Certificate ef Compliance-valid until(3 years from dete o�rep �tJ: <br /> ❑ No#�ce of Noncomplience-For Noncompliant systems: <br /> The tEason fo�noncompllance is: , _ -- <br /> This noncom�liant system{s classlfled as(che�k one be ow): . <br /> [] Imminerrt threat to public heafth&safety �Falling to p �tect ground water �]Not in compllence with operating permli <br /> CE t'tifiC7�1o17 (Completed form must be submRted to 1he locel un t of gbvemment within 15 days.j <br /> 1 hereby certlfy thet all the t�ecessery informetion has been gatheie to detemiine the compllanae status of thls system. No <br /> determine6on of future sysfem perlerm�nce hes been nor can 6e ade due to uNmvwn condl�ons during syslem conshucHon, <br /> possible abuse of iHe system,lnedequate mafntenance, or future ter wsage. <br /> Name: �'�'�?�.��.�L.'rJ' ��'����-S �ewfiqtion numbe� �_v_��] <br /> Business Ilcense name and nulnbe� ,S -� '�(G� y�.��.J`�.�'�,��lo� � N'��'3 S��o, or <br /> Name o f loc�l un i t o f go v e n m�t: -.......,—.- <br /> Signature: �� ��-�'- ----� Date: 1 D -��-0� <br /> I p <br /> Required Attachmenfis . lnspec�or cpmP��ce:Thls Inspection Report is FJ pages long. <br /> Check eemp��ance farnts ettalehed: I�Nydtaulie Partormence ��e�nk tntegrlly �Soil Separatan ❑Operating pemnit Fortn(If <br /> epplicabl�) �Sy9kem drewing/Aa-bulit drewleg I]An e99essinenk of mr IW:aI requlrelnents khet are diffierent from what Is roqulrod on thla <br /> Fcrm ■Soil6o�ing LoAs ❑lo►►bandanment�orm(If approp�iate) C1 O er l�ortnatbn(Ilst�: <br /> Upg�de Requiremenls(dedved flom Mlnn,Stat�115 55)An�mm ¢nt fNrsaf fo publlc haaRh�+nd sehrfy(17'PHSJ rtivat bc up�adod,roplaced,or <br /> Rs usa dlswnUnuCd w�(Hln fen monfhs of IEeelpt of thls r►otic9 or wllhln s sl�oder d if rlaqWrod by bc+N Gd/nence.ll fhe systsm f4 fi,�11ing fe P►nt6ef prbund <br /> wa(er,fhe syslero must bA upgrndPd,repleeoal,or Ils uae dbconNnu¢d w!!hM 0►e nequbad by Ibcs/ordp+ance.If�n eidatlng systom fs not fapMp as deM�ed In <br /> ►aw,anal hos at Mns!fwo�eef ot ar�slgn sM►aeParanon,d�sn tAs sysfem need ewf o uppradetl,ropaAod,rcpleced,ar Ifs uso dlscontlnued,nWwlthseandln0 eny <br /> bcef o►dMence 8►�!l5lnofe af�lct Th�s p1oVIs�DA eloes not epply to sysEo�ns►n 611 lend ereea,WeNhe�d PiotocRon M!es,or drose used M oonnecflon wlfh lbod, <br /> bav�7o,and lodpin.q eafeWlsnmehfs os dallned!n law. i <br />. I <br /> wq-wwists�(•31 , � Compl�iQnce Inspection Fornt for k7cisting SSTS <br /> 4/1/08 . I <br />