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Minnesota Pollution Control Agency SSTS Abandonment <br />520VItte Road North Reporting Form <br />St. Paulaul,, 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. Slat. <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 Informati�on� ' _ s <br />Date of abandonment: 11. 11 1'Ll'/'�1 Reason for abandonment: j7bA;W,j�RW.fj <br />Property owner name(s): <br />Property owner's address: <br />City: _ State: _ Zip: _ <br />Site address ( erent): p�(�__ <br />City: QQ _ state Zip: <br />Compliance Information <br />1. All solids and liquidrs removed from all tanks? XYes ❑ Nol.( <br />Disposal Site:J-(� <br />2. All electrical devices and devices containing mercury removed? ❑ Yes ❑ No <br />Disposal Site: 1A___ <br />3. All underground sewage tanks crushed and filled with soil or rock material? KYes ❑ No or <br />Removed and disposed off site? ❑ Yes ❑ No <br />Disposal Site: <br />4. Contaminated materials* re irJov�nd disposed off site? El Yes ❑ No <br />Disposal Site: <br />5. All underground cavities" crushed and filled with soil or rock material? ❑ Yes ❑ No or: <br />Removed and disposed offs(te? ❑ Yes ❑ No <br />Disposal Site: N <br />6. Future discharge to system permanently denied? A Yes ❑ No <br />Method(s) used: <br />"Contaminated materials = Distribution media, sail 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 5ubp.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-ww1sts4-03 • 11121108 Page i of 2 <br />