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Jti l. 25. 2012 3; O7PM No. 0718 P. 4 <br /> � �..,a;r�, ��� '�IVrinnesota Pollution CQ�"�'� liance I ns ecfiion For. <br /> • ��v�'�, Control Agency � P m <br /> ��i'� Existin Subsurfac� Sewa <br /> 520 La�ayeKe Road No�th S 8e T�tment Systems <br /> S�.PaUI,MN 55155-4194 �s�s� <br /> Dx rype:Comalien�e end E�roement <br /> Instructlons: inspection results based on Minnesote Polludon Corrirol Agency(MPCA) For Iccal trecki�g purp�es; <br /> requiremenis and attached forms—additional local requlrements may also apply, <br /> Submit completed brm to I.ocal Un1t of Oovemment(LUG)and syst'm�r <br /> wEfhln 15 day� <br /> System Status <br /> System status on d�e(mm/ddfyyyy): � - �1-�2 � <br /> � Compliant—Certificafie of Compllance ❑ Noncompliant—Notice of Noncompliance <br /> (Velid/or 3 yaars fian report date,un/ess shorter time (See Up�rBdo Requirementa on pagie 3) <br /> �frame�iuNiried in Local O�a►inance.) <br /> Reason(s�for noncompll�nce(check all eppflcable) <br /> 0 lmpect on Public Health(Complisnce Component�#1)—Imminem thre�t M public heafti►end safefy <br /> ❑01her Compllanoe Condi�ons(Complience Compa►ent#3)—Imminent thre�t b publio haeUh and sefiaty <br /> ❑Tank Imsgrily(Complience Component �—Failing ta protect�ourtdwater <br /> (]Other Complianoe Conditions(Compl/ance Componenl#3)—Fei�ing Go pr+�tect gioundweter � <br /> ❑3oil Separedon(Compliarnae Canp�eot #4)—Failing to p�cf groundweMr <br /> ❑Operating permit/monitoting pla�requirements(Compliance Comp�ent #5)—Noncanplient <br /> Property Informat�on pa�r��or s�rwprRan�e: <br /> Properiy address: I'1 2�S E-1►a�.1�( �� � Reason for inspedlon; ' ' <br /> Properly owner. [.���c, � \��_� ��iQ,q,� Owne�'s phone: aSa,— 4�3—'S6��f 1 <br /> or - <br /> Owne�s represeMalive: Representaiive phone: <br /> Looel regulatory authority: G t�'� �r o�1.1 O Regulatory authori�r phone: <br /> Briefsyatemdesuiption: �o�,1�A�N �'Q-V�� i000,�al e�os►uv-�A�.1wC�lti+,w�� (9 v aal M �vC�-P�o Cd�a) <br /> Comments or r�ecomm�nalat�a�s: 150o g�,l 'C'uw� Lw�p.�6g �p �.�v�,q-��a ��,,,q��,�a s�r�v� �� <br /> �o�w�5� as'xyo' <br /> Certification <br /> 1 hereby ce�fify fhaf a/l fhe necessery inf+orme6o,n hes been gathered to detertNne ths oomp//ence status of tias sysl�em.No <br /> det�emtlna�on of fiut��e syst+am perfn�manoe has been nor cen be mede due to unknown condiNons during syst�em Gonsfn�bon, <br /> possi6le abuse of the eystem,inadequal�e maintenance, or hdw��ler usege. <br /> Inspecto�name: � L' Cerdfication number. !�a� <br /> 8usiness name: � � Lic�enae number. 3�y- <br /> Inspector slgnature: Phone numbsr: �Ilo��� � n(o <br /> Necessary or Locally Required Attachmentis <br /> ❑Soil boring Iogs []System/As-built drswing ❑Fotms per loc�l ordinance <br /> ❑Other infom�etion pist): <br /> .......��� �r��� �� ..� ItrI �11�I ♦9M nl�w i���w�. �...... �.� ��.� ��� '����. . . ._ . . <br />