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. ��� \� <br /> a . . x of <br /> ��, r- � � <br /> Minnesota Pollution � <br /> Control Agency <br /> ��" Compliance Inspection Form <br /> 520 Lafayette Road North �isting Subsurface Sewage Treatment Systems (SSTS) <br /> SG Paul,MN 55155-4194 Doc Type:Compliance and Enforcement <br /> r <br /> Inspection results based on Minnesota Pollution Control Agency(MPCA) � For local tracking purposes: <br /> requirements and attached forms-additional local requirements may also apply. <br /> Submit completed form to Local Unit of Govemment(LUG)and system owner <br /> within 15 days j <br /> System Status <br /> System status on date(mm/dd/yyyy): 10/15/2012 <br /> ❑ Compliant—Certificate of Compliance � Noncompliant— Notice of Noncompliance <br /> (Valid for 3 years from iepo�t date, unless shorter 6me (See Upgrade Requirements on page 3.) <br /> frame outfined in Local Orclinance.) <br /> Reason(s)for noncompliance(check a!I applicable) <br /> ❑ Impact on Public Health (Compliance Component#1)-Imminenf th�at to public health and safety <br /> ❑ Other Compliance Conditions(Compliance Component#3)-Imminent ti►�at to public health and safety <br /> �Tank Integrity(Compliance Component#2)-Failing to protect groundweter <br /> ❑Other Compliance Conditions(Compliance Component#3J-Failing to protect groundwater <br /> ❑ Soil Separation(Compliance Component#4)-Failing fo protect groundwater <br /> ❑Operating permiUmonitoring plan requirements(Compliance Component#5)-Noncompliant <br /> Property Information Parcel ID#or Sec/Twp/Range: 0611723230017 <br /> Property address: 4720 NORTH ARM DRIVE WEST,ORONO _ Reason for inspection: PROPERTY TRANSFER <br /> Property owner: Owner's phone: <br /> or — —_——_. _ — .— — — __-- -------- -- <br /> Owners representative: _THAI XIONG_ _ _ _ ___ Representative phone: <br /> Local regulatory authority: CITY OF ORONO ___ Regulatory authority phone: <br /> Brief system description: 2) 1000-GALLON SEPTIC TANKS, 1000-GALLON LIFT TANK AND PRESSURIZED MOUND <br /> Comments or recommendations: <br /> Certification <br /> 1 he�by cerfify that all the necessary informafion has been gatheried to determine the compliance status of fhis system. No <br /> determination of future system perfom►ance has been nor can be made due to unknown conditions during system construction, <br /> possible abuse of the system,inadequate maintenance, or future water usage. <br /> Inspector name: Ryan Lashinski _ Certification number: 3053 <br /> Business name: Lashin i orated License number: 65 <br /> Inspector signature: . • Phone number. 612-919-3704 <br /> Necessary or Locally Required Attachments <br /> � Soil boring logs �System/As-built drawing ❑Forms per local ordinance <br /> ❑Other information(list): <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282•5332 or 800-657-3864 • Available in alternative formatr <br /> wn-wwists4-31 • 3/16/12 Page 1 of 3 <br />