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I. <br /> ' ` � 'Minnesota Pollutian ���1YED <br /> � �. g�.£ � Compliance Inspection Form <br /> ' ��� Control Ag�nty <br /> rv SZ�����������rt� JUN O� 2Q��xisting Subsurface Sewage Treatment Systems <br /> s�.��ut,MN 55'155-419+� ������� (SSTS) <br /> Doc Type:Compliance and Enforcement <br /> Instructions: Inspection results based on Minnesota Pollution Control Agency(MPC or local tracking purposes: <br /> requirements and attached forms—additional local requiremerrts may also apply. <br /> Submit completed form to Local Unit of Government(LUG)and system \� <br /> within 15 days / <br /> �' s� <br /> System Status � <br /> System status on date(mm/ddtyyyy): y �3 <br /> �Compliant-Certificate of Compliance ❑ Noncompliant-Notice of Noncompliance <br /> (Valid for 3 years from ieport date, un/ess shorter time (See Upgrade Requirements on page 3) <br /> frame outlined in Local Ordinance.) <br /> Reason(s)for noncompliance(check all applicable} <br /> � ❑ Impact on Public Health (Compfiance Component #9)—Imminent threat to public health and safety <br /> ❑Other Compliance Conditions(Compliance Component#3)—lmminent threat to public hea/th and safety <br /> ❑Tank Integrity(Compliance Component #2)—Failing to protect grpundwater <br /> ❑Other Compliance Conditions(Compliance Componenf#3)—Failing to protect groundwater <br /> ❑Soil Separation(Compliance Component #4)—Failing to protect groundwater <br /> ❑ Operating permiUmonitoring plan requirements(Compliance Component #5)—Noncompliant <br /> Property Information Parcei i�#or secrrwpiRan9e: <br /> Property address: �(SQ yi.,v�,� �SS Reason for inspection: �A- � - <br /> Property owner: Owrier's phone: <br /> or <br /> Owner's representative: Representative phone: <br /> Local regulatory authority: �� ,.,- � � ��OqI`O Regulatory authority phone: <br /> Brief system description: <br /> Comments or recommendations: <br /> Certification <br /> I hereby ce�tify that al!the necessary information has been gathered to determine fhe compliance status of this system. No <br /> dete►mination of future system perfo►mance has been nor can be made due to unknown conditions during system construction, <br /> possible abuse of the system, inadequate maintenance, or future wafer usage. <br /> Inspector name: � Lr�/ �p� ���q/ Certification number: � 7j� <br /> Business name: t � (,�Cf c .re/ S �t . v License number: �d f <br /> Inspector signature: Phone number: �G3— �/,Z�f ' 7�7�Q <br /> Necessary or Locally Required Attachments <br /> �Soil boring logs f�]System/As-built drawing ❑ Forms per local ordinance <br /> ❑Other information(list): <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TfY 651-282-5332 or 800-657-3864 • Available in alternative formats <br /> wq-wwists4-31 • 1/24/12 Page 1 of 3 <br />