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� ��:��`- �NlPhnesota Pollution Com tiance Ins ection Form <br /> :_;� �,'�,�- <br /> � �r : <br /> ��:�a� Controi A enc <br /> ''���"`� � y Exis�ing SubsurEace Sewage T�reatm�nt Systems <br /> � 5�0 Lafayette Road North <br /> ��.Pgui,MN 55155-4T94 �S�T$� <br /> Doc 7'ype:Compllance and Er�foroentenf <br /> Instructions: lnspeciion results based on Minr�esota Polluution Controf Agency(MPCA) �or local��j�p��p�e�s: <br /> requirements and attached forms-additional loca!requfremeMs may also appiy. ��11f <br /> Submit completed farm to Locai UnEt of Oovsrnment(l.E1G}and system owner ��P Q � ���� <br /> wKhin 15 days � <br /> C��'��ORONO <br /> System Status <br /> syatem statua on date(mm/ddlyyyY): $ � 5 ^1 � <br /> � Compiiant-Certif�cate of Compiiance ❑ Noncompllant-Notice of Noncompliance <br /> (Valld for 3 years/rom r+�port dafe,uriless shorfer 6me {Ses Upgrade Requir�menfs on page 3) <br /> fr�me ouHfned fn Locel Ordlnance.} <br /> Reason(s)for noncompliance(check el1 appllcable) <br /> ❑{mpact on Public Health(Compliance Componet�t #�)-Imminent tftreat b pubGc health and safety <br /> ❑Other Campllance Condfions(Compilance Component�i3)-lmmfnent threat to publk healhh s»d sefety <br /> ❑Tank Integrity(Compliance Component #2)-FailMg ta protect groundwater <br /> ❑Other Compliance Condi�ons(CompHance Componenf�.9)-Fa1Ung to protecf graundwafer � <br /> ❑Soil Separation{Complience Componenf #4)-FaJlfng to profecf groundwater <br /> ❑Operat�ng permitlmoni#oring plan requirements(Comp!lance Gomponenf #5)-Noncompllanf <br /> Property Information paroeE t�#or sec�rwp�ange: . 1��s,�,�.s� � . <br /> Property acfdress: 2�q`T S �,41�1�S� �-�� c�c��c� Reason for inspecf�on: �g�p�.� -(Q�S� . <br /> Property owner. Q��i L�41k'�1 Owner's phone: �1�7�� �a3—(C�'r!1� <br /> or � <br /> Owne�s representative: � FtepreseMative phone: � � <br /> Lc�cai regulatory auihority: :�:vt�•( �i� d4�a►�1,.�c� Reyulatory authorfty phone: _ °t 5 e1-al4-q -4 tovo <br /> Briefsystemdescrlpt[on: ��,5��.►-Zc�v�,�„} �s���-f�..t�r t'1.�i��,,,) R��n?�fi�.s.�G rfk�t.a r��o�a�.i.<i ' <br /> Comments�r recommenda�ons: ,S�s'�i w��tas �' �V'�•8�;'��Y�w, �i►z��o +�� �S- (o t��s�vw+ Yl�1n G� <br /> � � � . , <br /> Certification <br /> i hereby certity that al!the necessary lnfarm&Gon has beert gafhe�ed to defermJne the comptlance status of this sysfem.lVo <br /> dstem►inaBon of futur�system perfortnance has been nor esn be made due to unknawn cond%ns du�ing system constrt�ciforr, <br /> posslble abuse of the system,Tnedequste meFrrtena»ce, or firture water usage. <br /> Inspector name: �j-f�y{�� +�,•�jG��"�t��� Ce�tification number: {�a� <br /> Business name: -� � License number: �T4- <br /> Inspector signature: :��-= � , -L.-}-~-� Phone number. ��� ��q�} -�,5lato <br /> Necessary ar Locally Required Attachments <br /> �Soil boring logs �System/As-built drawing []Forms per local ardinance <br /> ❑Other informatiai(list): � <br /> ww�x,�Ca,state.mn.us • b5i-Z96-6300 � 80Q�657-3864 • �'i'Y b51-282•5332 or SOU-b57 3864 • Avaftabie in altematrve lormats <br /> wq-wwtsrsl-3f , f/24ll2 . <br /> t <br />