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t• Minnesota Pollution <br />Control <br />AgAgency <br />Compliance Inspection Form <br />C <br />520 Lafayette tioad North Existing Subsurface Sewage Treatment Systems (SSTS) <br />St, Paul, MN 55155-4194 Doc Type; Compliance and Enforcement <br />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 16 days <br />System Status <br />System status on date (mmldd/yyyy): _10- S -2,o <br />Compliant — Certificate of Compliance <br />(Valid for 3 years from report date, unless shorter time <br />frame oullined in Local Ordinance.) <br />❑ Noncompliant — Notice of Noncompliance <br />(See Upgrade Requirements on page 3.) <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 113) — Imminent threat to public health and safety <br />❑ Tank Integrity (Compliance Component 112) — Failing to protect groundwater <br />Other Compliance Conditions (Compliance Component 03) —t=ailing to protect groundwater <br />❑ Soil Separation (Compliance Component #4) — Failing to protect groundwater <br />❑ Operating permittmonitoring plan requirements (Compliance Component #5) — Noncompliant <br />Property information Parcel 10# or Secfrwp/Range: i,} 1�1 1 `<.� &0. <br />Property address: aaiijc 0 p Gly n �5 ��.SG. 212QO Reason for inspection: <br />Property owner: 5c.,c��(•i 1 4. ��( iy�l_ Owner's phone: ��a-30S -) S1 al <br />or <br />Owner's representative: Representative phone: <br />Local regulatory authority: Regulatory authority phone; °1 S;t ko00 <br />Brief system description; a - ofd v /y� p` `� c, �,✓„yMS' �Cv-+S�r t.10J}SQ <br />Comments or recommendations: 'rY; 4 IL�be` v1yt34T7 51z.t9p �o�rk c,�54:��i'nv�ryt opt f <br />Certification <br />I hereby certify that ail 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: ��:�/ ih\ (3 L�� � _ Certification number: _� ) <br />Business name: License number: L. <br />Inspector signature: �j� a Phone number: V123 <br />Necessary or Locally <br />® Soil boring logs <br />❑ Other information (1131): <br />Required Attachments <br />System/As-built drawing ❑ Forms per local ordinance <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-wWWA-31b • 614114 Poop 1 of i <br />