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Minnesota Pollution SSTS Abandonment <br />Control Agency <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:`f Reason for abandonment: <br />ra < < J <br />Property owner name(s):t <br />Property owner's address: 4i +o Z.Fi , � �,� l �>� !lr� Ve <br />City: u #tl State: Zip: �3 S <br />Site address (if different): <br />City: .f ; ( V-ev State: Zip: <br />,Compliance Information <br />1. All solids and liquids removed from all tanks? T�d- Yes ❑ No <br />Disposal Site's ,-1 <br />2. All electrical devices and devices containing mercury removed? PM Yes ❑ No <br />Disposal Site: (Y. e—re-cb- )C4 ( 140 P , (e ':"-e <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: - Vo I L <br />4. Contaminated materials* removed and disposed off site? ❑ Yes-Q No <br />Disposal Site: C ver- J & , <br />5. All underground cavities** crushed and filled with soil or rock material?pE 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 />'l14L_Gvt1- <br />Q C C%' i t n t. ,[h a c i <br />S L Q ✓. <br />*Contaminated materials = Distribution media, soil or sand within three feet of the system bottom, distribution pipes, geotex1 <br />t! 9' <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 armat�``��d <br />wq-wwists4-03 • 11/21/08 Page 1 of 2 <br />fi r .Lll' 1^ 'LO ve- ih0%< <br />lA i! <br />a c 3 ✓ <br />