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� ' � r�R��� MPIlnesotaPollution Compliance Inspection Form <br /> �� Control Agency <br /> 520 Lafayette Road North Existing Subsurface Sewage Treatment S�stems <br /> Si.P�ul,MN 55155-4194 (SSTS� <br /> Doc Type:Complla�toe artd EMoicerrrent <br /> Instrucdons: Inspection resutts based on Minnesota Pollution Control Agency(MPCA) For local tradclnp purposes: <br /> requirements and attached forms-additlo�al local requirements may also apply. <br /> Submit compleDed form to Loeal Untt of(iovemment(LUG)and system owner <br /> withfn 15 days <br /> System Status <br /> System status on date(mmldd/yyryy): � -a9��"� <br /> ❑Compliant-Certificate of Compliance �Noncompliant-Notice of Nonaompliance <br /> (Valld for 3 years hmm�sport date,unless shoRer time (See Upgrade Requlrements on page 3) <br /> /rame outllned!n Local Ordlnance.) <br /> Reason(a)for noncompliance(check ail appllcable) <br /> ❑Impad on Public Health(Compliance Cnmponent#1)-Imminent threat fo pubOc heatth and sa(ety <br /> ❑Other Compliance Conditbns(Canplianoe Componenf#3)-Imminent threat to publk heafth and safety <br /> ❑Tank Integrity(CompAance Com�arent#2)-Failing to pratecl groundwater <br /> ❑Other Compliance Conditions(Comp!lance Component#3)-Failing�o protecf groundwater <br /> ■Soil SeparaUon(Complianc�e Component#4)-FaDing to protect groundwater <br /> ❑OperaUng permiUmonitoring p�an requirements(Compliance Component#5)-Noncompliant <br /> Property Information Parcel 1D1�or SerlTwp/Range: Ikrdl.It,S,��. , <br /> Propertyaddress: �SS GOv��S�I��vJ v2. o4.�uc� Reasoniorinapection: �¢dp�it�( �����, <br /> Propertyowner. NOr�[.� 6�LYv� t7���1�1 . Ownersphone: . <br /> or <br /> Ownersrepresentative: � , Representative phone: <br /> Local regulatory authority: (�-(� oF O"4.194ao Regulatory authorlty phone: 9Sd -ay9-4b00 <br /> Brief system descripfwn: a.=I o00 0,d,S �fYa�.s.�5 4 �f¢G�..L ta.k� � <br /> Commenfs or recommendatlo� � . , , <br /> � <br /> Certification <br /> i hereby certily tltat aN the necessery fnfomtaUon has been gathered to determTne the compliance status of this system.No <br /> determinaffon of future system pedormance has been nor can be made due to unknown condl6ons during system construction, <br /> possibJe abuse of fhe system,inadequate maintenance,or firture water usage. <br /> Inspector name: �+(�Jy(�jc�1 ,�j. �L'NY�M�4 CertlfkaUon number. (o a� <br /> Business neme: � � License number. �q.t-�. <br /> Inspector signature: , �.�.� �,� Phone number: �J(o� ��.}q�-3 5�n(v <br /> Necessary or Locally Required Attachments <br /> ��Soi!boring bgs �SystemlAs-built drawfng ❑Fortns per locat ordinance <br /> ❑Other infortnation(list): <br /> www.pca.sWte.mn.us • 651-296-6300 • B00•657•3864 • TfY 651-282•5332 or 800�657•3864 � Available fn altemative fotmats <br /> w4-wwktst-31 • f/24/12 <br />