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. ' ,��t ��F�neso=a Po�!Ut�°n Compliance lnspection Form �'�:= Control Agency s�o�at�yecce Road rtorch Existing Subsurfaae Sewage Treatment Systems 5G?aUl,MN 55155-4194 �SSTS� Doc Type:Compllence and Enforcamenf �tErEIVED Instructions: Inspectlon results based on Mlnnesota.Pollution ConVaf Agency(MPCA) For local tracking purposes: requirements end attached forms-addiUonai local requiremenks may afso apply. A�D � � �O�c Submtt completad form ta Locat Unft af Govemment(LUG)and system owner f1 I\ J wlthln f5 days CITY OF ORONO Sysfiem Status System status on date{mmlddlyyyy): t-} --�,1. .�� ❑Compliant--Certificate of Comp{fance �Noncampliant-Nottce of Noncompllance (Valld for 3 years from report dafe,uniess shorter ttme (See Upg�ade ftequlrements on page 3) frama ouUlned!n Local Ordlnance.] Reason(s)for nqncompliance(check all appficabie} - ❑Impact on Public Health(Compliance Component#!)-lmmtneqt fhreat to pub(Ic health and safety ❑Other Compitance Conditions(Compllance Companent�f3)-Imminent threat to pubflc heaflh andsa(ety ■Tank integ�ity(ComplJance Component#2)-Faqing to protect groundwater ❑Other Camp(iance Conditlons(Compliance Component Ik?)-Failing fo prrmtecf groundwafer �Soil Separatfon(Complfanca Componenf#4)-Fa!ltng fo protect groundwater ❑OperaUng permit/monitoring plan requiremenis(Compqance Gomponent#5j-Abnaompifant Praperty information ParcellD#orSedT'wplF�ange: ��1�s-��1�VL,.a Q.co , Property address: �50 2�nS�oFng-i c.�r��rc-�, ��,c v Reason for inspection; ��z--��(.(-�G{��—�,� Property awner. � �-.t�AW�..i 4a�i��n r.a • . , Owners phone: q S a��h� ,.�a q!i� ar ' - Owner'srepresaniative: __��.�C',�t�Z�„ RepresentetNephone: �-z,_q�p_ �U3o. Locel regulatory authority: Lt-(-( ��f p p-�y„�c) Reguletory authority phone: q!a-ay.g�y�vo BriefsystemdescripNon: ��,So+�1VOv�.,1 sF��yC�-S�c-S r�c�� I R��4.(�p•s.tiw ,r,- ��,,,�q �„�5�,�,� Comments or recammendations: Certification 1 hereby certlfy that sll the necessery information has baen gathered to detsrmine the camp0ance status of thls system.No daterminaGon of future system padonnance has been norcan be made due to unknown condfGons dudng sysfem construcdon, posslble abuse of the system,lnadequafa maintenance,orfutura water usage. inspectorname: �{{�jy�it�1 ✓,�j,•�L'1�S'4�t�r5lD�-� Cerdficationnumber. _ .fo.�,!� Business name: -�� 11�— L{cense aumber. ?,ci�-�' Inspector signatute: +..�� .��r^ Phone number. 7to� �t}c�r}-�c, � : Necessary ar Locally Required Attachments ��Soil boflng logs �SystertVAs-bullt drawing ❑Fortns per locel ordinance ❑Other,informaUnn(list): WWYt,pCa,Stdte.mtl,US � 451•296•6390 � 800•657•3864 � 'f7Y 651•181•5331 or 800�65T•3864 � Avaltable Irt altemative formats _....._._,,. . .,,.,., � � i i i ;