Laserfiche WebLink
No, 1534 P, 3 <br /> P,pr, 2. 2013 2:41PM <br /> � � .� T� ota Pollution Gompl�anc�� Inspect�on Form <br /> ,;�,��� N1i�tnes <br /> � �• [ontrot Agenty Existing Sub6urface$�'�9�T�estm�n!Systems <br /> ����;�, (SS'rS) <br /> 52p ta�yet[e R�d North <br /> 5�.Pa4��MN 55155-4194 poc Type:tA►npllence and EMolr:6�nt <br /> bn resutts based on Minnesola poNution Control Ager�CY(MPCA) <br /> For Iocal tracking pu��s: � <br /> Instrucdons: lnspecC �d�nal locaf requirements maY ai�O apply. <br /> requirements end aitached forms- <br /> Submlt completed fore►to W�a�uNt of DoVe�'nroent(I.UC'1 and aystem owr�r <br /> within 16 d�ys <br /> gystem Status <br /> sys�m s�on da�lmmldd�YYYY)� <br /> 3-a�-�3 <br /> Noncompliant-Notice df Nonr•ompliance <br /> []CompNant-Certific ote�o�Co�p�sh ��rr� � (��P�e�e9uiremerrts on pe9e 81 <br /> (Valid for 9 ye�B�m rep <br /> trame oudined in�ocal 0►dinance.) <br /> Reason(s)for noncomp�lance(check afl appllce��e) <br /> ►ance Component �1)--►mminent fhreat to pu6lic heafth and satety <br /> O 1mPa�on public Health(C�p�� ent�4)-Imminent thr�af to publk health and safery <br /> 0 pther Complis�Conditions(ComPliance ComPon ter. <br /> []Tank Integ�ty(���a���nent #2)-Fa�ling ta pro�er,t g�u� �u��r <br /> Q pther Compliano�CondMiong(C�P�ta►►ce�°1�p°"ent�)'"Fa��in�t�A��9 <br /> �Soil Sepe�auon(CompAenae Component #4)-FaiJ►ng b pro�ea�n�� I►ant <br /> �pperating pem�itlmonitpting P�a��'�9 <br /> uiremenis(Compl�ance ComAonent #5)-Noncomp� <br /> Propert�l �nformation pa��i�o�secRw��se� <br /> �'�.�A�\� f C� �. ' , <br /> �,.�1�"�.�1 ��ta�r'¢�7 <br /> �r- �Qu \r� Reesct�to���sPedion: �� <br /> Properh►add�ess: �' '0 �..�,�Cr�• 1�tit-��� , ne: ibS�•� �°Y`:'O1`-1-� <br /> �`.� �. Owners p� <br /> PropertY oxmer: 1��*1 '� �-�� : <br /> Qr RepresenteUve phone: � ., � <br /> Owne�s representalive: �. Re9ulalory authority phone: °►5���"�°� ��+^{ � <br /> ..G � n'G' . �.z�.7 -.:�. N%.�i�'Lv��..� <br /> LoCel re9u{atory authotity: � � ►a � �`�., - � <br /> Brief system description_ a�[n� � ;� , , � . � <br /> •COmments bf feCcxnmendatlons: �: • � , , <br /> ,�� � � <br /> C@I't��Cdt1011 red to determine the complianc�status af this system.No <br /> th�t all the necessaiY��fi°�effon has been gafhe m constructio�� <br /> I he►+eby ce+fify m erfortnence hea been nor can ba mede due i�unknown condtflons durin9� <br /> detertnination of futUre� p ua�ma�ntenance,orfi�tu�w�t�erusa9e• ( �,n <br /> ��p�e abuse of fhe sysrem•inadeq ���n number: <br /> ` �ii ,i ` t��4 <br /> lnspecto�name: � ` �`�� Lic�7se number. ��4- <br /> 6usiness name: 5~' '� Phone number: �+^'�, ��°��`�'�'��z�.�— <br /> Inspe <br /> ctor s[gnature: :`�' �, , '�`�~ <br /> N��essary or Lotally Requlred Attachments p Fotma per�oc��ord�nance <br /> �$oil bOdng loga �SystemlAs-bulR dra��9 . <br /> []pther information(Ila�: <br /> ,�,,,�,�,pc�.state.mn. <br /> ug � 651�Z�6-6� � �,��.38�q • 7T1f 651•282•533Z or 80�657•3964 • Availablc In altemative farmaks <br /> y„y_�srs4-31 • f IT4/f2 <br /> � <br />