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Oct 2 "12 03:47p 763-213-0695 p.1 <br /> � MinnesotaPoilution � m liance Ins ect'o <br /> Control Agency �� p p � n Form <br /> 520 i.afayette Road North � ����ng SubsurFace S�w�ge Treatment Systems <br /> 5t.Paui,MN 55155-4794 � � � ��TS� <br /> ��,r�,'��� Doc 7yp�:Compfiance and Enfaroeme�f <br /> / <br /> I structians: Inspection results based on Minnesota Pollution Control Agency(NfPCA] Far local tracking purposes: <br /> r quirements and attached forms-addit�ona�local requirements may also apply. <br /> bmit compEeted foren to Local Unit of Governmeeit(LUG)and sysbem owner <br /> ithin 15 days <br /> S stem Status <br /> System status on date(mmlddlyyyy): f�-, _ ��_ )�. <br /> � Compfiant—Certificate of Compliance ❑ Noncompliant—Notice of Noncompliance <br /> (Valid for 3 years!mm reporf date, unless shoder time (See Upg�ade Requrr�ments on page 3) <br /> frame ouflined in toca!Ordinance.) <br /> Reason(s)for�oncarnpliance (check all applicable) <br /> ❑ Impact on Public Heallh (Comp/iance Component #1J-,lmminenf threat to publrc heallh and safety <br /> ❑ Other Cornpiiance Conditions(Compliance Componer�t#3)-Imminerrt threat to public heafth and safefy <br /> ❑Tank Integrity(Compliance Companenf #2J-Failing to profect gr�undwater <br /> ❑Other Cornpliance Conditions(Compliance Component#3)-Fai(ing to protect groLndwater <br /> ❑ Soii Separation(Compliance Component #4J-Failfng fa prafecf groundwater <br /> ❑Operating pe�mitlmonitoRng pfan requirements (Compliance Component #5)-Noncomplrant <br /> � operty Information Parcel fD#or SeclTwplRange: <br /> Pr�perty address: (:C ' �' �' , �c�, p,t,c�2eason for inspection: ,:.,.: , <br /> Pr�perty owner: ' owner's phone: 7b 3� .33 J 1 S � <br /> or� <br /> Ovyner's representative: --- Representati�e phone: <br /> Lo�al regulafory authority: , Regulafory authority phone: <br /> Br�f system description� _ �'U.,r ; _ � <br /> C � rnents or recommendations: <br /> C rtification <br /> !h reby certrfy thai all the necessary rn/onnation has 6een gathered to determine the compliance stafus of this System. Nv <br /> de�ermination of future system performance has been norcan be made due fo unknown condltions during system construcfion, <br /> po�rble abuse of the syslem� dequafe maintenance, or future water usage. <br /> In ector name: U,✓ ._.-� ---' � <br /> Certification e�umber. �� �} <br /> Bu iness name: - ' � License number: �j �].�✓ <br /> Ins ector signabure: ��- Phone number: �('�,L{�= f �v <br /> N cessary or Loca�ly #tequired Attachments <br /> Soil�oring logs [�SystemlAs-built drawing �Fotms per loca[ordinarice <br /> Other inforrnation (Jist): <br /> .pca.state.mn.us • 65T�296-63D0 • 606-657-3864 • 7lY 651•282-5332 or804-657•3864 • Available in altemative formats <br /> wn- ierce_t1 . 1�7err� . <br />