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May 0812'04;13p 2 763-213-0695 p.1 <br /> r � � <br /> \ <br /> i <br /> Minnesota PoJlwtion r �,�� Compliance Inspection �orm <br /> . Control Agency � (�, <br /> 520 Lafayette Road North "J ���9 $��ce S�wags Treatmsnt S�at��s <br /> St.Paul,MN 55155-419� �S�•s� <br /> Doc Type:CompJianc�e and EnfcroemerK <br /> Instructions: lnspection results based on Minnesota Podution Control Age�cy(MPCA) F�����ng purposes: <br /> �equiremeMs and attached fortns-adddonal local requi�emeMs may also apply. <br /> Submit completed forrn to Loql Un�t of GovemmeM(LUG)and system vw�r <br /> withfn 15 days <br /> System Status <br /> System status on date(mm/dd/yyyy): � �- )��_ <br /> � Compliant—CerEificate of Compl�ance ❑ Noncompliant—Notice of Nancompliance <br /> (Valid fn�3 years from neporf�te, unless shorter time (See Upgrade Requiremer►ts on page 3) <br /> frame ouffined in Loca1�Orriinance.) <br /> Reason(s�for noncom�pliance(check a/l applicable) <br /> ❑impact on Public Health{Compliance Component #�J-Imminent ttrr�eat fo pubNc health and sefeiy <br /> ❑01her Compliance Condi6o�s(Caryuliance Component#3)-Imminerrt threat fo public heaA"Ir and safery <br /> ❑Tank Integrity(Corr�pTance Component #2)-Fail�g fo pro�ect grr�undwater <br /> ❑ Other Compiiance Cvndidons(CompGance Component#3)-FaiGng[o pr�tect grormalw�ater <br /> ❑Soil Separation{Cormpliance Component #4)-Far7ing to pratectgroundwater <br /> ❑Operabng permit/monitoring plan requiremer►ts(Compliance Component �,5)-Non�campliant <br /> Property Informatian � f parcel Ip#a Secl�wplRange: <br /> Property address: � � �1 i Reason ior inspec�ion: <br /> Property owner: � <br /> Owner's phane: <br /> or <br /> Owners represernalive: Representative phone: <br /> Local regulatory aulhorify: • ' Regulato authority phone: - -O 7 <br /> Brief system descriptio�: 000 � 0 0 � ¢ � � <br /> Comments or recommendations: <br /> Certification <br /> !hereby certily that a!!the neoessary infwmation has been gathered tv defemrine the compliance status of this system.No <br /> determinetion of future system pe�fom'ianCe has been nor cen be made due to unknvwn condifions during system co�sfructiarr, <br /> possible abuse ofthe system,irradequate msint�narrce, orfuiurie waterusage. <br /> Inspector name: ��� /���n_P,_�- CeN�cation number. 7� <br /> Business name: - � � �.r Ge S,S o=/ C• License number. o� 6 � <br /> Inspector signalur Pt�one number: 7� �y.Z�/�?/� <br /> Necessary or Locally Required Attachments <br /> �Sail boring logs �System/As-buift drawing �Fortns per local ordinance <br /> ❑Other irrfom�ation(list): <br /> www.pca.state.mn.us • 651 296-630Q • 800-657-3664 • TTY 6.ri1-�R9•5'tR7 nrlafl���7_�r�e . ...,:,.ti�..:....,«..__�:.._�_�_� <br />