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SSTS Abandonment <br /> form <br /> Minnesota Pollution <br /> Rep°rte(SST Program) <br /> encY tment gyste� <br /> Control Ag Wage Tres <br /> 520 Lafayette Road North <br /> N 55155-4194 $albsgtr�ace Stat• <br /> St.Paul,M Inn. <br /> osure Requirements of M' <br /> R 7080.2500 and Doi d SSTS- ent unit(1-GU) <br /> require be <br /> of Minn ceded by an aband <br /> Instructions dormant req n also be *tad to me►oral 90. Ual 0 has <br /> red to meet the aban well placement ca must be s s p or by Sill nd <br /> This form is offe a water supply may <br /> anoncompo this <br /> a Certified SSTS pradit►°ner <br /> 115.56,subd'6'Futur however the information on this fon <br /> this form is not mandat ant.This form <br /> The use of after the abandonm <br /> within 90 days of how the system was abandoned. <br /> direct knowledge <br /> Information ' / <br /> property 1 Reason for abandonment: � �---- <br /> ent: _ <br /> Date of abandonm <br /> property°wner name(s): 1 State: , <br /> Property owner's address: <br /> �– <br /> -' _ zip: <br /> City: State: �— <br /> Site address(if different)= <br /> City: - <br /> Compliance Information ? Yes [3 — — <br /> No - -- <br /> 1, All solids and liquids removed from all tanks. ❑ <br /> Disposal Site: <br /> mercury removed? C3 Yes <br /> 13 No <br /> 2. All electrical devices and devices containing -- <br /> Disposal Site: _— – --– ro cro 0 <br /> -- a tanks crushed and filled with soil or rock materiel? Yes ❑ <br /> 3, All underground sewag � Yes ❑No <br /> Removed and disposed off site. ❑ <br /> Disposal Site: _--— <br /> 4. Contaminated materials`removed and disposed off site? C1Yes [INo <br /> Disposal Site: <br /> 5. All underground cavities"crushed and filled with soil or rock material? Yes ❑No or. <br /> Removed and disposed off site? ElYes ❑No <br /> Disposal Site: <br /> 6. Future discharge to system permanently denied? Yes ❑No <br /> Method(s)used: <br /> 'Contaminated materials- Distribution media,soil or sand within three feet of the system bottom,distribution pipes,geoteotile <br /> fabrtclrosin paper/straw,tanks,contaminated soil around leaking tanks,any soil that received sewage <br /> from a surface failure(7080.2500 subp.3). <br /> pump <br /> ••underground cavities= Cesspools, subp.ing 1). Does not include its,drywells, chamber media,drop boxesge pits,vault pri%jes,pit, distt ributtion boxes. <br /> www.pca.state.mn.us 651-296-6300 • 800.657-3864 TTY 651-282-5332 or 800-657-3864 Available in altemative formats <br /> wq-wwists4-03 11121108 Page i of2 <br />