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MINNESOTA POLLUTION Sewage tank CONTROL AGENCY 520Lafaymelt)WNorth maintenance reporting form St. Paul, MN 55155-4194 Irl, bsurfacO $OWtis! TrOatltl3mnt Systems ($ST$) Program Purpose: Management and maintenance of Subsurface Sewage Treatment Systems (SSTS) are important to ensure resource protection and long-term and cost-effective sewage treatment. Completion of this form complies with the sewage tank maintenance requirements under Minn. R. 7080,2450 and 7082.0600. This form may be used to certify the compli nce t8 tus ofthe may sewa aomporoft of the SSTS. This form is not a complete 55TS inspection report, only a tank Integrity only cersf)1 sewage tank compliance status when entirely completed and signed on page 3 by a qualified professional. Irtstructlons: A Dopy of this hkwmadon must be subm ttsd to the system owner within 30 days of the maintenance date and be maintained by the k wmad SSTS maintainer business for a period of five (5) years from the maintenance date. Malnilertiance reporting W lite kx:el unit of gmemmmt may be required by local ordinance. Check with your local SSTS program for maintenance reporting protocol. Secure maintenance hole covers All maintenance hole covers must be returned to service in a sound and durable condition and be capable of withstanding the anticipated load. Covers must be re -secured in accordance with Minn. R. 7080.2450, subp. 3, Items C or D: ary 4, 2008 must be locked, bolted or screwed or must be 95 a) Covers Installed under local ordinances adopted after Febru pounds in weight They must be made of material suitable for outdoor use, resistant to ultraviolet degradation and lurks, and not susceptible to being slid or flipped. They must have a label waming of hazardous conditions inside the tank. All screw openings must be refastened. b) Covers installed under local ordinances adopted before February 4, 2008 must eitherbe buried with at least 12 inches of sail cover or be secured according to the local ordinance in effect before February 4, 2 008. C) Covers must most Item `a' above when raised to the ground surface or less than 12 inches from the ground surface. Reporting information 10102!20 1 Reason &Com tierce Ins tion Date of maintenance (rnmlddlyyyy) ..,._. 003_ Patel #p: 041172343 _ Property address: 2675 Fox St zip code: 55,391 cW. ©rono _ state: MN _.. _ . Property owner's ,tame: Victoria Ter Property -owner's address if different - State. — — - dip code: _ _ — Phone number: 612-730-1081 Email address: victoriategyj ft_msn c orn 1. Did you measure the accumulation of scum and sludge? ❑ Yes ($ No (tank(s) pumped without measuring) _Tank (check if praseny -- Scum Slud$e OPera die nth Percent full — _JELS9.�clholdjng tank #1 - _RSeptirJholding tknk #2 —. - - — — — -- — — — .Q Pretreatment tank — 2. Access used to remove septage: Maintenance holes 0 Other (Unless a holding tank, go to #4 below) 3. If the maintenance hole was used, were all covers secured in place? ji Yes ©No If no, please explain below: 4. if the oyster refuses to allow a Subsurface Sewage Treatment System (SSTS) to be pumped through the maintenance hole, have them complete and sign the following statement - 1., refuse to allow the removal of the solids and liquids through the maintenance (Print aWiw name) hole. I understand that removal of solids and liquids through other access points is not considered a compliant method o solids removal and does not fulfill the solids removal requirements of Minn. R. 7080.2450 and 7082.0600. By W#ngisigsing my name below, I certify the above statements to be true and correct, to the best of my knowledge, and that this information can be used for the purpose of processing this form. Owner's signature: _. Date (mmlddhryyy): A WWW.pca.st3te.mn.us •— 651-296 63ai 800-657-3864 Use your preferred relay service n Available in altemitive formats Page Y of 3 wq_wwists4_38 • lAof21