Laserfiche WebLink
May. 14. 2012 12:39PM No. 0472 P. 3 <br /> ;;Y Minnesota Pollution Compliance Inspection Form <br /> ' ;�, ,. Control Agency <br /> 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems <br /> St.Paul,MN 55155-4194 (SSTS) <br /> Doc Type:Compliance end 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(mm/ddlyyyy): 9-d1•.a�,- <br /> ® Compliant—Certificate of Compliance 0 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 /> Reasons)for noncompliance(check all applicable) <br /> '❑Impact on Public Health(Compliance Component #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(Compliance Component#3)-Falling to protect groundwater <br /> ❑Soil Separation(Compliance Component #4)-Farling to protect groundwater <br /> ❑Operating permit/monitoring plan requirements(Compliance Component #5)-Noncompliant <br /> Property Information Parcel ID#or SeclTwp/Range: <br /> Property address: '4 01SO Q cc, c 'Q Qo*Tj Reason for Inspection: cizolt 4-1 .(1q,14s.t- <br /> Property owner: 'Qa L-41.4\, Owners phone: c1 SZ-?,7 t7 - y 1 <br /> or <br /> Owners representative: _ Representative phone: <br /> Local regulatory authority: G r4( i* 01,0$.40 Regulatory authority phone: g ti z-'a. <br /> Brief system description: , . ., `.Y y /, A . - w1 a ,� .5 - A �-� ( l'( <br /> Comments or recommendations: 5t.<6.<0..yfrI I S o o vc�.t w a .L, .- '.... 5t(s�Y\ c\vs.,c <br /> Fo a' - 1-1ovw <br /> Certification <br /> 1 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 future water usage. <br /> Inspector name: yf'Oy 6. S -\ c-h r, Certification number: to.a") <br /> Business name: 5 � y�.ti License number: 3q�LF <br /> Inspector signature: < Phone number. 1(03 <br /> 49,1 5 S iota <br /> Necessary or Locally Required Attachments <br /> Soil boring logs ®System/As-built drawing 0 Forms per local ordinance <br /> 0 Other information(list): <br />