02-01-2021 Septic Pumping/inspection report

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IMINNESOTA POLLUTION CONTROL AGENCY 520 Lafayette Road North St. Paul, MN 55155-4194 Sewage tank maintenance reporting form Subsurface Sewage Treatment Systems (SSTS) 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 compliance status of the sewage tank components of the SSTS. This form is not a complete SSTS inspection report, only a tank integrity assessment, and may only certify sewage tank compliance status when entirely completed and signed on page 3 by a qualified professional. Instructions: A copy of this information must be submitted to the system owner within 30 days of the maintenance date and be maintained by the licensed SSTS maintainer business for a period of five (5) years from the maintenance date. Maintenance reporting to the local unit of government 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. 70802450, subp. 3, Items C or D: a) Covers installed under local ordinances adopted after February 4, 2008 must be locked, bolted or screwed or must 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 less than 12 inches from the ground surface. Reporting information Date of maintenance (mm/ddtyyyy): Reason for maintenance;1� Al? t Property address: l ��_ 2i-7 ( �.4 t� _ _ Parcel ID: City: &A,- ��. J y Sta e: MAI_ Zip code: Property owner's name: t;�)c -4. �.o Property -owner's address if different: _ _ City: _ State: _ Zip code: Phone number: Email address: 1. Did you measure the accumulation of scum and sludge?_ -E Yes ❑ No (tank(s) pumped without measuring) Tank (check if present) Scum Sludge _ Operating depth Percent full ,,�e ticp /holding tank #1 _ Se tic/holding tank #21._ F1 Pretreatment Pretreatment tank tank "Pum 2. gf]Access used to remove septage_ ,, Maintenance hole ❑ Other (Unless a holding tank, go to #4 below) 3. If the maintenance hole was used, were all covers secured in place? ,�es ❑ No If no, please explain below: ACTUAL SIZE OF TANKS- TANK#1 TANK#2TANK#3 4. If the owner refuses to allow a Subsurface Sewage Treatment System (SSTS) to be pumped through the maintenance hole, have them complete and sign the following statement. I, _ , refuse to allow the removal of the solids and liquids through the maintenance (Print owner's 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 typing/signing 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): www.pca.state.mn.us 651-296-6300 800-657-3864 wq-wwists4-38 0 1/7/21 • Use your preferred relay service • Available in alternative formats Page 1 of