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Minnesota Pollution Control Agency SSTS Abandonment <br />520Lafayette Road North Reporting Form <br />St. Paulaul,,MMN 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 />Q rf <br />Date _ <br />ry-AlY. Reason for <br />���L/\WA <br />,oryfabandonment: <br />/t t7 1�.,�_ <br />-abandonment: _�� <br />C9,2f ✓/.+�tl\ C-"�/1 !4✓ <br />.a� t.ic�e. s� /<{u`1�r�of <br />�A.a (.. <br />Property owner name(s): <br />David Klema <br />Property owner's address: <br />40 Orono Orchard Road <br />_ <br />City: Wayzata (Orono) <br />State: <br />MN <br />Zip: 55391 <br />Site address (if different): <br />City: <br />Compliance Information <br />1. All solids and liquids removed from all tanks? ® Yes ❑ No <br />Disposal Site: <br />State: <br />2. All electrical devices and devices containing mercury removed? ❑ Yes ❑ No IVA <br />Disposal Site: <br />3. All underground sewage tanks crushed and filled with soil or rock material? N Yes ❑ No or <br />Removed and disposed off site? ❑ Yes P9 No <br />Disposal Site: <br />4. Contaminated materials' removed and disposed off site? ❑ Yes ❑ No IV A <br />Disposal Site: <br />5. All underground cavities" crushed and filled with soil or rock material? ❑ Yes ❑ No or: r,O/r <br />Removed and disposed off site? ❑ Yes ❑ No <br />Disposal Site: <br />6. Future discharge to system permanently denied? ❑ Yes ❑ No NA <br />Method(s) used: <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-wwlsts4-03 • 11/21/08 Page 1 of 2 <br />