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� � Minnesota Poilution Compliance Inspection Form <br /> Control Agency <br /> s2o l.sfayptte r�oad Natl, �� ���°T�t1N1t Sy�slfle (�TS� <br /> SL Pau�MN 55155-4194 Doc 7ype:(�mp�anos e►►d F.r�rae�r� <br /> Inspsc�tion rosulrs besed on�A6�r�e�PoNutlon ConMol Ag�(NIPC�►) For local tradcirp purposea: <br /> �and aaad�ed fo�ms—addi�ior�al bcel neqte�ements rnay slso apply. <br /> Submit compleled fam bo Local Unit of tiovsmment(WG)and system oMrr� <br /> within 1 S daps <br /> S�/St@ii1 S�t�JS <br /> Systiem slabus on d�be(nMnlddlY�lyf►I- 6/242015 <br /> � Canpliant—CertNica�e of Compliance ❑ Noncompliant—Notice of Noncompliance <br /> (Ve�d fior 3 yssrs fiom report dsi+e,�w►lesa s/w�ter t�ne fSee Up�de Require►►►e�ts on page 3.J <br /> fisme a�tlined in Locel Ordin�►oe.) <br /> R�son(sl fior na�on�liana(cl►edc all ap,pll�blel <br /> p�mpad on PubGc He�llh(Comp�anoe Con�pa�nt�1)—�n�minenr am�ro p�c hea�era s�y <br /> ❑Other Complisnoe Conc�tlons(ComplJenoe Component�3)—1►nn�IneM riNeat b pubUc heelrh e►M s�ety <br /> ❑Tank Inte9ritY(Conp�snoe Con,pdwM�2)—Fa�Nn9�P�� <br /> ❑Other Cornpliance Conditior�s(Co�r�p�noe CornponeM�3)—Fa�in9�P�9� <br /> ❑SOiI Separatlon(Con�►�e Cort�o�nent�4)—Fa�in9 b Pided 9roundwe�►' <br /> ❑OP��B P��9 psn�(�e��1—�� <br /> Property Information �io�or sedrwprRsnge: ���8-xi-�-oo�a <br /> Property addross: 70 NMt�e�rood Rd. Reason i�inspecdon: Transfe�af ProPeKY <br /> Prop�ty owner. Joaeph and Zoe 9weraa� Owners pho�e: 952-23A-OP25 <br /> � <br /> Owners repr�dve: R�pNone: <br /> Locai regulelory swlioriyr. He�xbpin County Regulalory aulliorily plw�� 612-b43-5212 <br /> B�ief system desaiptlon: 2-1000�aqon seplic tanks and a 1000�on tanic�0 8 3 bedroom Droesuro�ed mound <br /> Comments or ncommsnda�ons: <br /> Systerri was pumped and deaned in�xrx�af 2014 and w�l be due for anotlter main�oe de�ning in aurKr�of 2017 <br /> Certification <br /> i ne►eay oe�ary n�r�n►e neoea.,a►y�,nea r,e��a►e►.d rv de�e�►►�►�e a►e oorr�oe ac�,s ormra ay�r�.nro <br /> det�enr�nadion of ffuhm�sya[em ps�fionnanoe has been nor can be medie�e ro uMv►own cand�fans dwfng s�rn ca�6rudfo�n, <br /> pa4sible alwse oithe sya�e�siadequa�s n�lenanoe,arluhne waterusag�e. <br /> Inspedor narr�e: Tristan Ende Ce�tion rKenber: C9206 <br /> Business name: Lioense rnar�ber 12654 <br /> ir�spe�signa�e: T � Phone�ximber: 783-4'L8-4489 <br /> Necessary or Localty Required Attachments <br /> �sa�boring bgs �SystemlAs-b��in arawing ❑F«ms per bc�l oroinanoe <br /> ❑Other ir�forrr�tion(�ist): <br /> www.pca.scaee.�,.us • ��-z�-63o0 • eoo�s�-� • m 661-2�-5332 or SOO-657-3a64 • �va�a�e tn u�emacwe rormacs <br /> wq-wwlsts4-31b • 6/4/f� ���3 <br />