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Feb ?2. 2016 04:35PM HP FaxRusty Olson 7634988290 page 2 ��� <br /> ��� <br /> MinnesotaPollution Compliance Inspection Form <br /> Control Agenty <br /> 520 Lafayette Road North Existing Subsurface Sewage Treatment Systems <br /> St.Paul,MN 55t55-�194 (SSTS) <br /> Doc Type:Compliance and Enforcement <br /> DCrCIVCf1 <br /> Instructions: Inspection results based on Minnesota Pollution Control Agency(MPCA) �� For local tracking purposes: ? <br /> requirements and attached forms-additional local requirements may also apply. 'I rCD Z Z 201 c <br /> rC� � <br /> Submit completed form to Local Unit of Government(LUG)and system owner <br /> within 15 days <br /> Systern Status <br /> System status on date(mmJddlyyyy�: 2120l2016 <br /> g Compliant—Certificate of Compliance ❑ Noncampliant— Notice of Noncompliance <br /> (Valid for 3 years from report date, unless sho�ter time (See Upgrade Requirements on page 3) <br /> frartte outlined in Loca/Ordir,a»ce.) <br /> Reason(s)for noncompliance (check a!1 applicab/e) <br /> ❑ Impact on Public Health (Compfiance Component #i)-Imminent fhreatto pub/ic hea/fh and safety <br /> ❑Other Compliance Conditions(Complrance Component#3)-lmmrnent threat to public heaJth and safety <br /> ❑Tank Integriry(Gompliance Gomponenr #2)-Failing to protecf groundwater <br /> ❑Other Compliance Conditions(Compliance Component#3)-Failing to profect groundwater <br /> ❑Soil Separation(Gompliance Component #4)-Failing to profecf groundwaler <br /> ❑ Operating permiUmonito�ing plan requirements(Compliance Component #5)-fVortcomplianf <br /> Property Information Parcel ID#or Sec/TwplRange: 04-117-23-34-0003 <br /> Property address: 2611 Fairview Lane, Orono, MN Reason for mspection: Property Transfer <br /> Property owner: Kate Tabner Owner's phone: 917-864-6666 <br /> o r —" <br /> Owners representative __ Representative phone: <br /> Local regulatory authoriiy Ci of Orono Regulatory authority phone: 952-249-4600 <br /> 2-1000 gallon septic tanks,i-1000 gallon lift station and 500 squa�e feet of mound rockbed, per city <br /> Brief system description: records <br /> Comments cr recammendations: <br /> Certification <br /> !hereby certify that all the necessary informaGon has been gafhered to detemiine fhe compliance status of this system. No <br /> determination of furure system performance has been nor can be made due to unknown conditions dunng system construction, <br /> possible abuse o/the system,inadequate mainfenance, orfufure waterusage. <br /> Inspector name: Joseph J Olson Certification number: 1255 <br /> Business name� Rust son's Soil&Perc. Test�ng �icense number: 810 <br /> Inspector signature: Phone number: 763-498-8779 <br /> Necessary or ocally Required Attachments <br /> � Soil boring logs � SystemlAs-built drawing ❑ Fo�ms per locai ordinance <br /> ❑ Other information (list): <br /> www.pca.state.mn.us • 651-246-6300 • 800-657•3864 . TTY 651-282•5332 or 800•657•3864 • Available in alterra[ive formats <br /> wq-wwists4-31 • f/24/12 Page 1 of 3 <br />