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� . . <br /> �� <br /> Paroei number. System status: ❑Comptiant ❑Nonc�mpliant <br /> (as dete�mined by this form) <br /> Certlflcate of Abandanm�ant <br /> Date of observation: �2��� Reason for observafion: �e�.S�/.f f'��''� ��'�' TGn k'� <br /> CompUance questionsJcHteria:(Chedc the appropriate box) <br /> To be in compliance,systems with no future intended use for sewage or dean water disc�arge must be abandoned in accordanoe <br /> Minn. R.7080.2500 as determined below: <br /> Were all the solids and liquids removed from tt�e system? �J Yes ❑No <br /> Were all electrical devices and devices containing meroury removed? /=A_ ❑Yes ❑No <br /> Were ail underground tanka temoved tanks aushed nd fiiled with soil or rodc material? �Yes ❑No <br /> Were all underground cavities removed or soii or rodc material? �Yes ❑No <br /> •Any"no"answ�eis lnalfcates!he system!s fa/ling[v protect gramd w� <br /> Propertyownername(s): _ �"A�r' C- K �o��'�i l��n <br /> Property address: �7 90 S f!v c f (/;e w Q�l u C <br /> Property owner's address(if dff#ereM}: <br /> County: �{�/►/1 _ Phone: <br /> Certification <br /> This form is to be oompleted and attached to the Summary Form of the Minnesota Pollution Conirol Agency's(MPCA)Cwnpliance <br /> Inspectlon Form for Existing SubsurfaCe Sewage Treatmerrt Systems(SST8).This form does not have to be completed by a <br /> certified SSTS practttioner,but must be campleted by the individual who has knowledge of how the system was abandon. <br /> Completed form must be submitted to the local unit of govemmeM within 90 days. <br /> !hereby certi/y the system was abandoned in acacordanc+e with Minn.R. 7080.2500 and any/oca/roqufrements. <br /> Name: � Certification number. <br /> Busin s lioense name and number. � � r^�� �. G���s�� e-� <br /> Business add ss: I `�.� �A �t iQ U e �t�p�O, <br /> Signature: Date of abandonmeM: ��Q S��'� <br /> wq-wwlsts4-31 Compl fonce lnspection Form for Existing SSTS <br /> 4/1/08 <br />