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'hllhnnesota Pollution <br /> Compliance Inspection Form <br /> Control Agency <br /> Existing Subsurface Sewage Treatment Systems <br /> 520 Lafayette Road North <br /> St.Paul,MN 55155-4194 (SSTS) <br /> Doc Type:Compliance and Enforcement <br /> Instructions: Inspection results based on Minnesota Pollution Control Agency(MPCA) For tracking purposes: <br /> requirements and attached forms-additional local requirements may also apply. th by CL Of <br /> 010134 <br /> Submit completed form to Local Unit of Government(LUG)and system owner / t J <br /> within 15 days / <br /> II <br /> System Status <br /> System status on date(mmiddtyyyy): L-to-tic{ <br /> 0 Compliant-Certificate of Compliance MI 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 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)-Falling to protect groundwater <br /> Q Other Compliance Conditions(Compliance Component#3)-Failing to protect groundwater <br /> lm Soil Separation(Compliance Component #4)-Failing to protect groundwater <br /> C]Operating permit/monitoring plan requirements(Compliance Component #5)-Noncompliant <br /> Property Information Parcel ID#or SeciTwp/Range: <br /> Property address: 1'1 3 O o`q cR-4-Xi trcri,4-(Qom,;v'S-Za rs v Reason for inspection: M' <-(i4 s -• <br /> Property owner. Owner's phone: . <br /> or <br /> Owner's representative: +l.c1 rc4k•,1d0Wfi.A-- Representative phone: LM? ..-440 - <br /> Local regulatory authodty: t.►.•(-< 010).1O Regulatory authority phone: a&Z.-'? S° -W V O <br /> Brief system description: 1e-'1000 a ,A<AA IUoei e4.14avwi,-1040,Y- 4 3 4 arn-isOh <br /> Comments or recommendations + <br /> Certification <br /> I hereby certity 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: 6, Certification number. (a a,fl <br /> Business name: 5"4 '��'� yS 1�j 14L� , License number. -2,0/,/,! <br /> Inspector signature:Y � <br /> � �(1, ✓"' Phone number '7 --4q r)-3 ralo(o <br /> Necessary or Locally Required Attachments <br /> 33 Soil boring logs El System/As-built drawing ❑Forms per local ordinance <br /> 0 Other information(list): <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats <br /> wq-wwists4.31 • 1/24.112 <br />