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� Minnesota Pollution SSTS Abandonment <br /> Control Agency <br /> 420 Lafayette Road North Reporti ng Fo rm <br /> St Paul,MN 55155-4194 <br /> Subsurface Sewage Treatment Systems (SSTS) Pr+ogram) <br /> Instructions <br /> This form is offered to meet the abandonment requirements of AAinn.R.7080.2500 and Disdoeure Requiremenb of Minn.Stat <br /> §115.55,subd.6.Future water supply well placement can also be affeded by an abandoned SSTS. <br /> The use of tMs form is not mandatory;however the infonnatlon on this fortn must be submitted to the local government unit(L�U) <br /> within 90 days aPoer the abandonment.This fam may be comple�d by a c�e�ifled SSTS pracMioner or by an indivldual who has <br /> dired knowledge of how the ayste�n was abandoned. <br /> Property Information <br /> (P-��t7 Idew Home Devel m <br /> Date of abandonme�rt - - Reason for abandonment: op ent <br /> Property owner name(s): Irwin 8 Alexandra Jacobs <br /> Prop6Rr owners address: <br /> City: StaGe: Zip: <br /> Site address(if different): 1700 Shoreline Or <br /> City: Orono g��; MN Zip; 55391 . <br /> Compliance Information <br /> 1. All solids and liquida removed irom all tanks? �$Yes ❑No <br /> Disposal Site: <br /> 2. Ali electrical devk;es arul deviaes�ntaining mercury r�wved? ❑Yes ❑No N/A <br /> Disposal Site: <br /> 3. Ali underground sewage fanks crushed and fllled with soil or rodc material? �Yes ❑No or <br /> Removed and dispaged oif site? ❑Yes �$No <br /> Di�osel Site: <br /> 4. Contaminated materials'removed and disposed off site? (�Yes ❑No <br /> Di�Osal Site: <br /> 5. All underground cavilies"crushed and filled with soil or rodc material? �Yes ❑No or. <br /> Removed end�Sposed otf site? ❑Yes �No <br /> Disposal Site: <br /> 8. Future discharge to system permanenHy denied? �Yes ❑No <br /> Method(s)used: <br /> •Concmrtinated rrwterlafs= DtsMbution rt►ediQ,soil or wnd wJthin three feet of the system bottan,dlstrlbudon plpes,gentextlte <br /> jabrlc/rasfn pcpsr/straw,tanks�contaminoted soft around teakrng tanks,arry soll that recNred sewage <br /> fram c surjoce jallure(7i0B0.2500 wbp.3). <br /> "Underground cnvldes e Cesspools.leaching plts,drywe(Is,seepage pits,vmelt prlvies,pit prlvles,pwnp chmnben <br /> (7060.2500 subp. 1).Does not fndude chamber medlc,drop boxQs,or dtstributlon boxes. <br /> www.pca.state.rt�.us • 651-296-63Q0 • 800-657-3864 • TTY 651-282•5332 or 800-657-3864 • Available in altemative fortnats <br /> wp-wwlsts4-03 • f 1/2i/OB Poye 1 of 2 <br />