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Minnesota Pollution <br />Control Agency SSTS Abandonment <br />520 Lafayette Road North Reporting Form <br />St. Paul, MN 55155-4194 <br />Subsurface Sewage Treatment Systems (SSTS) Program) <br />Instructions <br />This form is offered to meet the abandonment requirements of Minn. R. 7080.2500 and Disclosure Requirements of Minn. Stat. <br />§ 115.55, subd. 6. Future water supply well placement can also be affected by an abandoned SSTS. <br />The use of this form is not mandatory; however the information on this form must be submitted to the local government unit (LGU) <br />within 90 days after the abandonment. This form may be completed by a certified SSTS practitioner or by an individual who has <br />direct knowledge of how the system was abandoned. <br />Property Information <br />Date of abandonment: -Z Z- Reason for abandonment: VIOI�" 2t�—A <br />Property owner name(s):Q I <br />Property owner's address: 021 YS- $_t <br />City: 0 111_'7/1i _ <br />Site address (if different): <br />City: <br />Compliance Information <br />1. All solids and liquids removed from all tanks? Yes E] No <br />Disposal Site: h ,q <br />State: <br />State: <br />AJ Zip: <br />2. All electrical devices and devices containing mercury removed? ❑ Yes ❑ No <br />Disposal Site: <br />3. All underground sewage tanks crushed and filled with soil or rock material? [Yes ❑ No or <br />Removed and disposed off site? ❑ Yes ❑ No <br />Disposal Site: <br />4. Contaminated materials* removed and disposed off site? ❑ Yes ❑ No tilg <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? ❑ Yes ❑ No <br />Disposal Site: <br />6. Future discharge to system permanently denied? [,Yes ❑ No <br />Method(s) used: <br />Zip: <br />*Contaminated materials = Distribution media, soil or sand within three feet of the system bottom, distribution pipes, geotextile <br />fabric/rosin paper/straw, tanks, contaminated soil around leaking tanks, any soil that received sewage <br />from a surface failure (7080.2500 subp.3). <br />-Underground cavities = Cesspools, leaching pits, drywells, seepage pits, vault privies, pit privies, pump chambers <br />(7080.2500 subp. 1). Does not include chamber media, drop boxes, or distribution boxes. <br />www.pca.state.mn.us 651-296-6300 800-657-3864 TTY 651-282-5332 or 800-657-3864 • Available in alternative formats <br />wq-wwists4-03 • 11121108 Page 1 of 2 <br />