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08/19/2011 13:55 9528733112 PAGE 01/05 � Minnesota Pollution Campliance Inspection Form Control Agen�y 520LalayetteRoadNorth Existing Subsurf�e Sewage Treatment Systems (SSTS) x S�.PauI,MN55155•4194 Instruc[ions on page � �� Parcel number. " � � For Local TraCking Purposes 5ystem siatus: Compliant ❑ Noncompliant �� .�, (based on aH co lianc@ requirements) � � , Summary Form � � Property Information � Property owner name(s); Property address; �Gll` � Properry owner's address pf different); County: P perty ner phone � Per itting authority: ,- .._,,.._.__....—._ ..._._ Dale system�onstructed: � Reason for inspection: � _ _ __ System Description 8rief system description:l�� _�G��/I ... Locai pertnit number __ Numb r of bedrooms: _� Design flow rate; _.�� . Is the system� i In Shoreland area? ❑Yes �No In Wellhead Proiectlon Area? ❑ Yes rvo An U,S, Environmental Protection System serving a Minnesota Oepartment Agency (EPA) Class V Injection Well?[] Yes �No of Heath (MOH) Ilcensed facilify? ❑ Yc�s �vo /\ COr�lplld�Ce StdtuS(Basedon state requirements–additional local requirements may also apply,) Based on Che infnrmaGon gathered and raported on attached forms,the compliance status oi this system is(cher.k en�� �rtificale of ComplianCe–valid until (3 years lrom dete o(report); ________ ❑ Notice of Noncompliance- For Noncompliant systems: The reason For noncompllance is: _ ___ _ _ This noncomplfant system Is classffled as(check one belowj; Q Imminenl t�reat to public health 8 saFety ❑ Failing lo prolecl ground wa�e� ❑ Not in compliance with operat�nq per!�;� CertiflCatlOfl (Completed form must be submitted to the Iocal unit o(government within 15 days,) 1 hereby certify that all the I1eCessary intprmafion has be�n gethered io determine the compliance stafus of this systen� r•�_ deierminafion of futUle system performance has been nor can be made due fo unknown CondifrorlS Ou�ing sysfe�n co��srrc��;,��` poss;ble abuse otlhe system, inadequafe meinfenance, or/uture werer usage. Name: _.��(��]!�lY'[�,��(1.C� CertlFicatlon numbor. ��p�_"1,._..._., Business license name and number: �j.�tQ,S�L, �5��, __.. __._. or Name ot iocal unit of nme , Signature; .'_-- Da�e; _q �_1/... . . .. Required Atta hments Inspector Complete: This Inspection Report is �pages long. Cheek eompl ee fo�ma attached; �ydraulic Performance (�ank Integrlry �il Separalion ❑Operating Perm�l Form i�� applicable) 5yst�m drawinglAs•huilt rarwng ❑An assessmenl oi�hy local requi emenls thal are oiffe�enl �rom wnai is reqwreo On �^�� form ❑ Soi ng Logs ❑ ACanOonment fortn (if approprlate) ❑Otner inlortnation (If�tj: UPgfede ReqUif9R19ntS (d9llvdd(lam MI/1/1.$fBI, § 915,55J An immine�f�A/eal IvpubliCAeallfl and saJety(1TPHS)mustDe upgraoea.��p��cCc ; �ts vse oiscan►inueo wl�hln ron montha d rocelpl ol Ihla nolfce or wlrh/n A sAoRer pe�iod if iepvircd by IoCa!oro'inance.!(!hs system is la�nng ro proie�r;�o,:^� Na�o�.fne systom mvsl De up�re0ed,Ieplaced,or ifs use diaconfinued wilhln IAe lime requ�rea oy�ocal oralnA��e,f!an oY�St�n9 syslem�s�or�a��.;:g a>:ar: _: •• �sw,an0 ner af�ees!luro leel o/Oesipn aoil seDeraf�on,fAen Ihe sysfem need no�bc�pgradod,r�paJrcd,roploced,Of i19 u3Q OrSCOrll�nued.non.,rrs��r,-.:�; �-. roeal o�dmanre Inal is�r+o�s sfiicl, TAis Dro�is�on does nol apPlY lo syslams in sAorelan0 aress, We!lneo0 profCClion Areas,or lnore�.veC�r�;�n+;r�•�,;:: ,.. _,_ oeve�age, ana looqing eslenrr'snments as oerned in lsw, ._ . ....._._, e. � � , � - • - --...