10-28-2021 Septic Compliance - Laserfiche WebLink

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M:�.`, MINNESOTA POLLUTION Sewage tank : CONTROL AGENCY 520 LafayeM Road North maintenance reporting form St. Paul, MN 55155-4194 Subsurface SeW&W Treatment Systems (SETS) Progr&m Management and maintenance of Subsurface Sewage Treatment Systems (SSTS) are important to ensure nesovrce purpose: tank maintenartc4 protection and long-term and cost-effective sewage treatment. Completion of this form complies with the sewage requirements under Minn, R. 7080.2450 and 7082.0600. This form may be used to certify the compharme��mtus of he sewage ay tank components of the SSTS. This form Is not a COmptete SSTS inspection report, only a tank integrity usslified rofer3sional. only certify sewage tank compilanca status when entirely completed and signed on pageby 4 p Instructions: A copy of this hfcmw ion must be submitted to the system owner within 30 days of the maintenance date and be maintained by the kwmW SSTS maintainer business for a period of five (5) years from the maintenance date. Maintenance reporting to the local unit of governmeit 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: a) Covers Installed under local ordinances adopted after February 4, 2008 must be locked, bolted or screwed or roust be 95 pounds in weight. They must be made of material suitable for outdoor use, resistant to ultraviolet degradation and leaks, and not susceptible to being slid or flipped. They must have a label warning of hazardous conditions Inside the tank. All screw openings must be refastened. b) Covers installed under local ordinances adopted before February 4, 2008 must either be buried with at least 12 inches of soil cover or be secured according to the local ordinance in effect before February 4, 2008. c) Covers must meet item 'a' above when raised to the ground surface or fess than 12 inches from the ground surface. Reporting information Date of malntensnce (mmldtiryyyy): 10102/2021 — Reason for maintenance: Maintenance & Compliance Ins tion Property address: 2575 Fox St _ _ _ _ Parcel ID. 04117234300Q3--- City Orono _ _ _ State: .MN -- _ zip code: 55391 Property ownses name: VictoriaTerry Property.,owner's address if i1ft ent - State:- ` zip Vie: - — —� — Phone number. 612-730-1 Email address: victoriaterryl Ca msn com -- 1. Did you measure the accumulation of scram and sludge? © Yes No (tank(s) pumped without measuring) Tank (check 4 pnwentj -- Scum Sludge _ Operating pth _ Percent full — IglhoI incl tank #1— �Septkhtoidingtank.#2— Q Pretreatment tank— _RPumP—t-ank- 2 Access used to remove septsgs: ${ Maintenance holes[] other (Unless a holding tank, go to #4 below) 3. If the maintenance hole was used, were all covers secured in place? 0 Yes j] No If no, please explain Wow: 4. If tate owner refuses to allow a Subsurface Sewage Treatment System (SSTS) to be pumped through the malntenance hole, have them complete and sign the following statement refuse to allow ttte removal of the solids and liquids through the maintenance (Pow ownar'a name) hole. I understand that removal of solids and liquids through other access points is not considered a compliant method of solids removal and does not fulfill the solids removal requirements of Minn. R. 7080-2450 and 7082.0600. By W#nglsfgnirref 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 (mmldd/yyyy): use your preferred relay service — Available in akernatW formats www.pca.state.rnn.us 651-296.6300 800-657-3864 page 3 of 3 w¢1Nwjsts4-38 ■ IP121