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I . .. l <br /> ?s' w= Minnesota Pollution Compliance Inspection Form <br /> Agency <br /> Control "' <br /> Wedge Sabeirface SewageSystems <br /> 520 Lafayette Road North 'h�611ent <br /> St Pard,MN 55155-4194 (MTS) <br /> Doc Type:.[aorrlpliencs end Enforcement <br /> Instructions: Inspection resume based on Minnesota Pollution Control Agency(MPCA) For loot folding purttoses: <br /> requirements and attached torrrrs—additional local requirements nuy alio apply. <br /> Submit completed form to Local Unit of Government(LUG)and system owner <br /> within 15 days <br /> System Status <br /> System statue on date(mrnldd►imny): 5 '-`�` / __/Lj <br /> Q Compliant—Certificate of Compliance XNoncompfant-Notice of Noncompliance <br /> (Valk(for 3 yeas horn report date,unless shorter time (See Upgrade Requirements on page 3) <br /> frame a outlined In Local Onfrhance.) <br /> Reason(s)for noncompliance(check all applicable) Scanned <br /> ❑Impact on Pubfic Health(Compliance Component 01)—Imminent tlreat to pubic health and safety <br /> Other Compliance Conditions(Compliance Component 13)—Imminent threat to pub&health and safety <br /> NI Tank integrity(Compliance Component 12)—Fang to protect groundwater <br /> Other Compliance Conditions(Compliance Component 03)—Fairing to punted groundwater <br /> Solt Separation(Compliance ce Component*4)—Falfig to prated groundwater <br /> ❑Operating permltlmonloring an requirementa(Compliance Component 15)—Noncornpfient <br /> Property Informa <br /> tion f� n Parcel 1Da or Sec/Two/Range:e: <br /> Properly address: S 5. Reason for inspection: 9..!: <br /> 4 <br /> Property owner: -(ia,u' r-. • oemer e phone: <br /> Or <br /> Owners representative: Representative phone: <br /> Local regulatory authority: f C• . . Regulatory phone: <br /> Brief system description: 7 . 'int rr5O • r. ,: y ! r r /, l� <br /> Comments or recommendations: r r r <br /> Certification <br /> I hereby certify that all the necessary information has been gathered to determine the compliance status of this system.Alp <br /> detenrdnafon of Uwe system performance has been nor can be made due to unknown conditions during system construction, <br /> possible abuse of system,inadequate • ,odidure water'MOIL <br /> inspector name:. o% — nkd �i� Certification number: _ <br /> Business name: - ��% LY license number: 3 73 <br /> Inspector signature: ; /�� �,f— � Phone number*ii-Hill t ItYiS <br /> Necessary or Locally Required Attachments <br /> c Soil boring logs RSyotem/AM-built drawing I Forms per local ordnance <br /> 0 Other information(Ast): <br />