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Map <br />Include location of building sewer, septic tank(s), soil dispersal system, cesspools, seepage pits, and other pits. Also include a <br />permanent reference point(s) and dimensions. <br />'r North <br />14.Plastic Tank Removed <br />Multiflow Removed <br />Concrete Tank used for forced main to city sewer <br />Certification <br />I hereby certify the system was abandoned in accordance with Minn. R. 7080.2500 and any local requirements. <br />Name (please print): Asher Judd Title: Owner / Operator <br />Address: 588516P Street N <br />City: Hugo State: Minnesota Zip: 55038 <br />Phone: 651-983-1976 Licerw6# rapplicable): L4272 <br />Date: f25 Signature: <br />Please do not send this completed form to the MPCA. The information on this form must be submitted to the local government unit <br />(LGU) within 90 days after the abandonment This form may be completed by a certified SSTS practitioner or by an individual who <br />has direct knowledge of how the system was abandoned. <br />https://www.pcasUte.mn.us • 651-2965300 800-657-3864 Use your preferred May senri a Available in alternative formats <br />wq-wwisW4-03 • 9126125 vo0e 2 of 2 <br />