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Minnesota Pollution <br /> . 3x Compliance Inspection Form <br /> r , Control Agency <br /> I Existing Subsurface Sewage Treatment Systems <br /> 520 Lafayette Road North <br /> '5t.P4ul,MN 55155-4194 (SSTS) <br /> Doc Type:Compliance and Enforcement <br /> Instructions: 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 Government(LUG)and system owner <br /> within 15 days <br /> System Status <br /> System status on date(mmldd/yyyy): 7 - 3. — t 4 <br /> IS Compliant—Certificate of Compliance ❑ Noncompliant-Notice of Noncompliance <br /> (Valid for 3 years from report date,unless shorter time (See Upgrade Requirements on page 3) <br /> frame outlined in Local Ordinance.) <br /> Reason(s)for noncompliance(check all applicable) <br /> ❑ Impact on Public Health(Compliance Corhponent #1)-Imminent threat to public health and safety <br /> ❑ Other Compliance Conditions(Compliance Component#3)-Imminent threat to public health and safety <br /> ❑Tank Integrity(Compliance Component #2)-Failing to protect groundwater • <br /> ❑Other Compliance Conditions(Compliande Component#3)-Failing to protect groundwater <br /> ❑Soil Separation(Compliance Component 1#4) Failing to protect groundwater <br /> ❑Operating permit/monitoring plan requirements(Compliance Component #5)-Noncompliant <br /> • <br /> Property Information Parcel ID#or Secllwp/Range: '. <br /> Property address: a a c oc.t-tS-<111k.T4041 . otti"?..4 Reason for inspection: 100012.e.-Z--c- ,Cf-441-3$ <br /> Property owner. Owner's phone: r �-`Q LJu e°1/1'6"-`110 <br /> or • <br /> Owner's representative: ctc .< • Representative phone: 5'1$S'?,. '4 13 — <br /> Local regulatory authority: vN( Oar O4-o'-4D Regulatory authority phone: q • <br /> Brief system description: a -11444,c---7 ?l-'""ti? '1'441)4V- .'Pral4 tAvc�s N 1(-3.X.C) <br /> Comments or recommendations: (aQ ,i-isel1,4 vorAk''4- )o`K C* -, <br /> *ac' 1/,- c "r-4-90vr )4-0‘111%, <br /> 1' <br /> Certification <br /> I hereby certify that all the necessary information has been gathered to determine the compliance status of this system. No <br /> determination of future system performance has been nor can be made due to unknown conditions during system construction, <br /> possible abuse of the system,Inadequate maintenance,or Mum water usage. <br /> Inspector name: 5 'V Certification number: (0..2.f <br /> Business name: 5 10, . License number. <br /> Inspector signature: Phone number. qtQ-t) — Slo(o <br /> Necessary or Locally Required Attachments <br /> MI Soil boring logs ®System/As-built drawing 0 Forms per local ordinance <br /> 0 Other information(list): <br /> wvicpca,State.m.u5 • 651.296-6300 • 800.657.3864 • Ti)'651.282.5332 or 800-657-3864 • Available in alternative formats <br /> .......,..d�r��_Zf . 1174119 <br />