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10/08/2010 01:50 7634975011 SPTESTINGINC PAGE 03/07 'rMinnesota Pollution: . ompliance� Inspection Form Control Agency 520 Lafayette Road North bsulrSystemsExisting SuSewage Treatment Systems (SETS) 5t.Paul,MN 55155.4191 Dor,Type.,compohnce and C-niorcement Instructions on page 6 Summary Form (Completed form must be submitted to the local unit of government within 16 days.) Parcel number; System status, 8 Compliant^y0 Noncompliant For local Tracking Purpos". (based on all compliance requirements) Property Information , —w. - Property owner name(s): Y-. oLA y-4 t6' .5� Property owner phone: to Properly address: _SIJL ,►.iU. 51-}� ��L� i c.�. fp 4m 0 Property owner address(If different): County; � )A Permitting authority: _ + Date system constructed: _.k 0 0 1 Reason for inspection: - - System Description Brief system description: Pi Local Local permit number: _ Number of bedrooms: _ Design Clow rate: sO Is the system: In Shorelend area? ❑Yes N No In Wellhead Protection Area? 0 Yes IN No An U.S.Environmental Protection System searing a Minnesota Department Agency(EPA)Class V Injection Well?0 Yes PR No of Heath(MDH)licensed.Ndlity? ❑Yes N No Compliance StatLIS(Based on state requirements-additional local requirements may also apply.) Based on the Information gathered and reported on attached forms, the compliance status of this system is(check one): [I1 Certificate of Compliance-valid until(3 years from date of report): E]Notice of Noncompliance-For Noncompliant systems: The reason for noncompliance Is:This noncompliant system Is classified as(check one below); 0 Imminent threat to public health&safety 0 Failing to;protect ground water 0Not in compliance with operating permit Certification i hereby certify that all the necessarylnfotmatlon has been gathered to determine the compliance status of this system.No determination of Adum system performance has been nor can be made due to unknown conditions during system construction possible abuse of the system, Inadequate maintenance, or future water usage. Name; �''% 921 - Certification number: _(o Business license name and number. 5-19 :!��45d113i,_11J_C_, 1.1 tc., �q��} p��Loa�4grl- , or Name of local unit of government: Signature: _ j�i.� �I L�---- Date: c) )_O Required ,Attachments ®Hydraulic Performance Tank Integrity 0 Operating Permit Form of applicable) ®Soil Boring Logs Soil Separation IM System draw)ng/As-built drawing Any local requirements that are different from what is required on this form 0 Other Information(list): Upgrade Requirements(derived pi qm Minn. Stet§115.5.5)An IMmrnent threat to public healthend mlegr(ITAHS)must be upgraded, ,replaced,or its use dit- antinued within ten months of receipt of this notloe or WMfn a shorter period if required by load ordinance.it the system is failing to protest ground water,the system must be upgraded,replaced,or its use d1wonfinuad within Hie time required by local ordinance.If an existing system is not falling as defined In law,and hes at least two fleet of design soil separation,then the system need not be upgraded,repaired, replaced,or its use discontinued,notwithstanding any local ordinance(he(is more shfcf This provisfon does not apply to systems in shoreland areas,Wellhead Protection✓areas,or those used in connection With food,beverage,and lodging establishments as defined in law. www.pca.state.mn.us • 651.296-6300 • 800.657.3864 TIY 651.282-5332 or 800.657-3864 • Available in altemauve formats wq-wWsts431 - 4124/09 Page I of 11